November 16, 2015

ICD-10 a Non-Event for Clearinghouses

By Betty Gomez

ICD-10 has been a non-event for clearinghouses, which are continuing to report little impact on their day-to-day business operations.

Availity, one such entity, has encountered a few minor issues over the past month, primarily related to data not being submitted correctly by providers or payers having slightly different interpretations of some of the Centers for Medicare & Medicaid Services (CMS) guidelines. Clearinghouses have been proactively reaching out to providers and vendors with high volumes of ICD-10 errors and working with them to correct the issues.

Change Healthcare, another clearinghouse (formerly known as Emdeon), tracked provider readiness at 98 percent within seven business days, and by the end of the month ended at 98.7 percent, with nearly 99.9 percent of claims coded in ICD-10.

Rejection rates appear to be holding steady or trending lower than they were under ICD-9. There also has been no change, or even slight decreases, in overall denials from both commercial and government payers. This may be in part because clearinghouses have implemented processes to identify and correct potential claim submission errors after they have been submitted to the clearinghouse but before they are forwarded to the payor. A good portion of Emdeon’s October remittance feedback was based on ICD-9 coded claims that were working their way through the payment cycle. November will offer a better indicator of the state of ICD-10 based payments and denials.

ZirMed, another clearinghouse, reports that through their payor denial monitoring to date, there are no significant changes in the amounts, number of lines, or category types being denied post-ICD-10.

For those who may not have such baseline metrics in place, Jopari Solutions offers the following advice: “establish ICD-10 benchmark metrics to identify issues early on, apply remediation, and measure process improvement.”

Below is an example of industry benchmarks that providers can apply to their post-ICD-10 implementation strategy:

  • Revenue payment cycle variance metrics                                                
  • Average time (days) from claims submission to payment
  • Denial rate variance metrics (payer/provider benchmark)
  • Percent of payment denials by type of denial code (CARC/RARC) Source of initiation (provider, vendor, etc.)

The Cooperative Exchange encourages providers to continue monitoring their pending and denied claims status and to track their reimbursement levels to quickly identify and respond to any negative spikes in activity. 

About the Author

Betty Gomez is the Cooperative Exchange ICD-10 liaison and the compliance manager/director of Government Healthcare Solutions for Xerox Healthcare, LLC.

Contact the Author

Comment on this Article

Related Stories

  • CMS Releases 2019 Proposed Physician Fee Schedule
    CMS proposes to change physician evaluation and management (E&M) coding with a drastic overhaul. EDITOR’S NOTE: The following report first appeared on RACmonitor on July 13, 2018 After soliciting comments from many stakeholders in the last year, the Centers for…
  • Is All Airway Protection Acute Respiratory Failure?
    Document it right on the front end; avoid fighting a denial on the back end I was recently asked about a post from Hospital Performance regarding acute respiratory failure and airway protection (https://soundphysicians.com/blog/2018/06/20/from-the-appeals-desk-acute-respiratory-failure-part-1-2/), and I wanted to expand on what…
  • Physician Clinical Documentation: The Lifeblood of the Revenue Cycle
    The “right documentation” is the central pivot point to the revenue cycle   Physician clinical documentation plays a critical role in any overall healthcare delivery model, including the life of the revenue cycle, which drives reimbursement for quality medical care…