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Updated on: January 10, 2017

New Year, New Policies, New Challenges

Original story posted on: January 9, 2017
Jan. 1 always brings fresh starts, both personal and professional. Many of us focus on how we can make improvements for the new year. Whether it is fitness, motivational, financial, or transformational, they all require the same thing: dedication and consistency. 

The same holds true in our professional lives, and January always reminds us of that. For those of us who love coding, sometimes this is our favorite time of the year. New and exciting code changes, the thrill of opening that new code book with highlighter ready, etc. For those of us who are not so much fans of the coding system, this time of year brings a lot of added stress.

New codes mean new policies, and new policies typically mean payment challenges, denials, appeals, and revenue disruptions.

Even though the new ICD-10-CM codes took effect in October, many disruptions due to those changes aren’t really felt until the new year, when the procedural changes happen. So January brings increased stress (which usually isn’t good if your new year’s resolution is a diet) that can be felt among all the staff in a medical practice.

There are some simple steps you can take every year to help overcome these issues and make your practice stronger in the process; think dedication and consistency. Employ these simple strategies to make sure your practice tackles the new year successfully:

1. Run a frequency report on both diagnosis codes and procedural codes. For example, more than one payor made policy changes regarding brow ptosis for blepharoplasty.

2. Review policy changes. Check all your main health plans to see what changes they are making for the new year. Also, keep in mind, not all changes happen on Jan. 1; for some, they don’t take effect until February, so make sure you look at effective dates to eliminate denials.
  • Revised coverage rationale for brow ptosis:
    • Modified coverage criterion addressing documentation requirements to clarify documentation indicating the specific brow lift procedure (e.g., supra-ciliary, mid-brow, or coronal direct brow lift versus browpexy) is required.
    • Revised coverage limitations and exclusions:
      • Added language to indicate browpexy/internal brow lift is not designed to improve function; it is considered a cosmetic procedure and is not a covered service.
In this situation, you would want to know the appropriate diagnosis codes for selection as well as make sure that your documentation supports medical necessity. Keep in mind that chart documentation and the associated diagnosis code selection help make the case for medical necessity. Also, remember, cosmetic services are not covered, so be sure to get ABNs signed for those cases not considered medically necessary by policy.

3. Provide updated ABN reasoning to clinical staff so that they are aware of policy changes and can collect the appropriate information.

4. Stay on top of communications, being as changes in policy usually disrupt payments. Most often the payor will communicate the issue once they determine the root cause; in some instances they will require you to resubmit and in some they will process internally. Know what is coming. When you see a rejection, report it immediately if it fits in the policy so that the health plan can make alterations quickly.

5. Make sure someone is checking your acknowledgment reports on a daily basis; this will alert you quickly to rejections and changes that may need to be made. Practices may sometimes forget this step.

6. Be sure to provide education to all staff members who impact the documentation and billing processes.

New codes will always bring new policies. With the significant ICD-10-CM changes we received this year, there were many payment disruptions while health plans made fixes. This will carry over to the new year with the new procedural changes. Dedication to the research and consistency in applying the change parameters can help streamline the efforts in your practice. Who knows, it may even inspire you to take on new challenges and improvements!
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 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.

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