Updated on: January 30, 2014

ICD-10 Exposes Crucial Gaps for Ancillary Providers

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Original story posted on: December 9, 2013

Mandy Willis, CCS, CPEHRThe looming implementation of ICD-10 is doing a great job exposing the gaps that currently exist in our healthcare delivery stream. One such gap can be found in the flow of diagnostic information from a physician to ancillary providers such as labs, imaging centers, and home health providers, just to name a few.

For the purposes of this conversation, we’ll refer to such entities as “non-diagnosing providers.” In short, these providers do not generate diagnosis codes, but rely on the diagnosis codes and/or terms provided by the referring or requesting provider. And as I have heard over and over, they are worried that the issues they face with diagnosis codes now only will get worse as we implement ICD-10.

Today, when a physician requires blood work or imaging to diagnose a patient or confirm a suspected condition, he or she completes a prescription or requisition form. These will include the type of lab work or imaging work to be performed, along with a diagnosis or several diagnoses to support the request.

Sometimes, a lab requisition form may include a list of commonly used diagnosis codes from which the physician can select. But more commonly, the physician already knows the diagnosis codes he or she will use to support the need for the lab or imaging service. As a patient, I have witnessed many physicians select diagnosis codes they knew would ensure that my health plan would cover the labs they were ordering; yet this was not necessarily my chief complaint. On the other hand, clinicians may select a code for a suspected condition before they have confirmation from testing. Or they may select a non-specific code, because that is the most accurate code at that moment. All of these scenarios shine a light on the inconsistencies in diagnosis coding that exist today. So, what happens on October 1, 2014?

As you already may know, there is a hint of panic in the air as we draw closer to the ICD-10 go-live date. Our focus and energy is targeted on ensuring that diagnosing providers, health plans, vendors, and clearinghouses can support, use, submit, and process ICD-10 codes on Oct. 1, 2014. Our laser-like focus has left little room to look at the broader picture or how we can work with and support our non-diagnosing providers. We may not be able to help them now, but we most certainly can look ahead and incorporate them into our post-implementation planning and ease their post-implementation fears.

So, how can we help our fellow non-diagnosing providers? Begin with a few simple actions.

  1. Communicate with your ancillary providers. One thing is clear: Communication is a necessity for successful implementation. Providers rely on each other for accurate diagnostic information, and health plans rely on accurate diagnostic information in order to apply benefits, reimburse claims, and analyze outcomes and measures. Let’s start with a conversation about how diagnosing providers can help non-diagnosing providers ensure that their health information and reimbursement needs are met.
  2. Analyze your current processes. If there are gaps or inconsistencies in providing diagnosis codes or information to ancillary providers today, it likely will get worse as ICD-10 rolls out. For example, if, as a diagnosing provider, an unspecified code is selected as a default, this may impact ancillary providers negatively when ICD-10 goes live. One of the great things about ICD-10 is the increased specificity, but there are still plenty of unspecified codes from which to choose. Unspecified codes have their purpose, but they should not be used as a default. As ICD-10 goes into use, health plans may begin to restrict the use of unspecified codes, which may in turn cause disruptions in claims processing and reimbursements.
     
  3. Plan for documentation and process improvement. If you are like everyone else, you’re just trying to get done what needs to get done in order to meet the Oct. 1, 2014 compliance date. This is perfectly fine. It is imperative that you can assign and submit ICD-10 diagnosis codes by that date to avoid major disruptions to your practice. But the work does not end here. In order to leverage the benefits of ICD-10, we must keep making improvements to our documentation and coding processes. Plan for these activities and make incremental changes to help in the transition. Work with your ancillary providers to better understand what they need from you to ensure that they have the most accurate diagnosis codes and information.

In the end, non-diagnosing providers serve a vital function in the healthcare world. If they don’t have accurate and complete information with which to provide services to patients, then patient care will be impacted negatively.

Everyone must work together to make sure ICD-10 provides value instead of becoming a burden.

About the Author

Mandy Willis is a Certified Coding Specialist and AHIMA Approved ICD-10 Trainer with 15 years of experience in the healthcare industry. She has worked in the small physician practice environment, commercial payer and Medicare and Medicaid. Currently, her focus is on assisting all sectors of the healthcare industry in making the transition to ICD-10.

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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.
Mandy Willis, CCS, CPEHR

Mandy Willis is a Certified Coding Specialist and AHIMA Approved ICD-10 Trainer with 15 years of experience in the healthcare industry. She has worked in the small physician practice environment, commercial and public payers. She is also co-chair of the Workgroup for Electronic Data Interchange (WEDI) ICD-10 Coding and Translation Subworkgroup. Currently, her focus is on assisting all sectors of the healthcare industry in making the transition to ICD-10.