April 28, 2014

ICD-10 and Benefits to Patient

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Ask most patients what ICD-10 is and you will get the same look that I get from family members when I describe coding to them – that baffled, deer-in-headlights look. But when you explain how a code can translate their complaints and conditions into an alpha-numeric code for payment, it suddenly makes sense.

 

But how can ICD-10 really benefit a patient? I use an example of an injury I received a few years ago to make a point. Now keep in mind, I am a seasoned healthcare professional. I know what to expect and how to handle things. When I explain the timeframes, you need to imagine the impact this case would have on a layman patient.

While traveling for work several years ago, I slipped and fell in an icy hotel parking lot where I broke both my ankle and wrist. I was out of state, out of network, and needed surgery urgently.

As I handed over my primary insurance card, I apologized, because I knew what was going to happen. At the time of treatment it was not known who would end up financially responsible. Would it be the hotel, workers’ compensation, or my personal insurance? Because we are not truly patient in healthcare and we want our doctors to get paid, everyone billed my personal insurance. Six weeks later, the hotel declared it an “act of God,” and workers’ compensation declared responsibility for the claims. By this time a lot of money had changed hands for services such as emergency room treatment, DME, prescriptions, surgery, and physical therapy, to name a few.

It took me more than two years to get it completely straightened out. That was after too many phone calls to treating providers, hospital systems, health plans, and others. Remember, I know the industry. As soon as I got the information from my workers’ compensation plan, I personally called everyone.

The problem? My personal insurance paid and no one wanted to rock the boat and do all the work required to go back and fix it. It was not until my personal plan started taking money back that I got action. I was steered toward collections services twice by companies not understanding it was no longer a balance billing issue, it was now a workers’ compensation issue. Two long years of working to correct it not only consumed plenty of my time, but that of countless others as well. Correcting the situation required many administrative tasks, including rebilling, refunding, researching, appealing, and waiting for resolutions.

Now think about this same situation in an ICD-10-CM world. If I could easily spell out that a patient fell on ice in the parking lot of a hotel while traveling for work, how could that help? First and foremost, personal insurance would have spoken up and said, “Hey, wait! We aren’t responsible for this claim and we shouldn’t pay.” No money would have changed hands and the claim would have been suspended until I provided the workers’ compensation information – or, in the worst/best case scenario, it would have been the patient’s own financial responsibility (thereby making sure the patient gets the information out quickly, lest he or she have to pay on their own).

Think about how much time could have been saved by the providers’ offices, the health plans, the pharmacy, the physical therapists, and, of course, the patient. There are many other examples on how the use of ICD-10 codes can benefit a patient, such as quicker, more efficient approval of services and procedures as well.

 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.