Updated on: November 21, 2016

ICD-10 is Risky Business

Original story posted on: August 17, 2015

The risks associated with the changeover to ICD-10 on Oct. 1 have been numerous and varied. Will there be increased allegations of false claims? Did the recent Centers for Medicare & Medicaid Services (CMS) clarification regarding “families” of codes alleviate concerns? Will the change really create a surge in improper payments? Potential legal ramifications aside, will there be increases in issues that concern patients? Will improved clinical documentation result in optimal coding? 


Like almost everything else related to this rapidly approaching transition, the correct answer is, “It depends.” Who or what is doing the coding? How do they or it determine the most accurate code? Can we safely assume that if things are going well now, we are in excellent position for the future? Have you reevaluated your risk areas? Based on very recent experiences, even more new concerns are rearing their ugly heads.

In this day of automation and electronic health records, native coding is typically assisted by digital means. In many cases, these programs have been working very well and assigning codes with excellent accuracy. However, some of us are learning that historical precedent doesn’t always translate to future reliability. A recent case study demonstrates how quickly and completely things can go wrong.

The physicians were doing their job well. In fact, the clinical documentation was excellent. It included laterality, specificity, and in some cases, the exact verbiage in the code descriptions. With very few exceptions, there were no major documentation changes required. The electronic health record (EHR) and code-assist programs were correctly assigning the ICD-9 diagnosis more than 95 percent of the time. In some cases, code assignment was correct 100 percent of the time. Because the verbiage in the medical record included the necessary details to assign appropriate and accurate ICD-10 codes, no one was prepared for how bad the audits look now when reviewing ICD-10 code assignment in test files or for dual coding! It’s not as though anatomy or basic terminology has changed. How can the exact same verbiage be coded correctly in ICD-9 and completely wrong in ICD-10? There’s no concern about being in the same “family” of codes here – it isn’t even the same species.

It is highly doubtful that this affliction affects only one or two artificial intelligence programs. It would behoove all of us who use these typically excellent products to redo a targeted risk assessment immediately. These errors are far-reaching. There are coding errors that could lead to improper payments. There are coding errors that could lead to denials of legitimate claims. Perhaps most importantly, there are errors that will lead to patients being misdiagnosed. As anyone who has ever tried to correct errors in a medical record and/or insurance file knows, it is essentially an impossible task. You may correct one, but the likelihood of correcting all is slim to none. 

Some of the more prevalent examples include coding personal history as current conditions or diseases, coding family histories as current patient disease, assigning confirmed diagnoses when none exist, coding completely inaccurate anatomic findings or body areas, assigning “junk” codes when the details needed to assign the most specific code are clearly stated, coding a completely inaccurate procedure; the list goes on and on. 

So, what does this tell us? Progress can be painful. We will need proficient human coders to review the codes assigned by electronic health records and code-assist products. We will need time to work out the bugs, and precious little time remains. We will need to work closely with our vendors to troubleshoot and resolve issues quickly and accurately. We will need to work closely with our physicians. We will need to be on high alert for any patient concerns about errors. 

The road to success will feature ongoing risk assessments, robust and frequent audits, and dynamic corrective action plans. The best way to fix claim errors is to not make them in the first place.

If you have not reassessed your risk, it’s time to make it a high priority.


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.
Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.

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