November 2, 2015

Off and Running with ICD-10, Yet Lessons to be Learned


Various industry agencies, organizations, payers, providers, and physicians are reporting that there has been a reasonably smooth start for such a gigantic undertaking as the recent implementation of ICD-10. Like all momentous challenges, there have been some hot spots, some notable failures, some minor toe-stubbing, and some smooth sailing. Keep in mind that many organizations have begun reporting on early poll results. We all know that those may eventually be proven accurate or erroneous in the final results. Given that those outcomes were expected, are there any lessons learned? Any things we could have done better? 


There is no doubt that the widespread industry pressure on all payors to conduct full end-to-end testing provided myriad opportunities to do it right. Given the number of issues, minor and not-so-minor, that have cropped up, if that robust testing had not been conducted it is extremely doubtful that we would be saying a collective “whew, it’s looking pretty good” on Nov. 1. We think the industry got it mostly right with the pre-implementation claims adjudication testing. 

Some payors, including Medicare contractors, did not do so well with internally critiquing their system updates for the live environment on Oct. 1. Granted, they are moving to correct identified issues promptly, but I would ask why those blatantly obvious issues have to be brought to their attention by providers or provider representatives. How could you not notice that you loaded incomplete LCD or coverage policies? Missing one or two, or even more, diagnosis codes out of thousands is completely understandable. Completely missing all the diagnosis codes specific to major anatomic areas is another issue entirely. We applaud the efforts to correct these types of errors quickly, and more importantly, reprocessing incorrectly denied claims. However, I believe the industry would have liked some internal vetting to identify glaring errors before incorrectly denying claims much more. Depending on your specialty and practice demographics, these types of delays can rapidly become a major cash flow disruption. For practices unfortunate enough to be affected by several cash flow disruptions due to these types of issues, it can be a critical matter. I think we could have done much better in this area. Simply having knowledgeable employees perform final accuracy checks on each policy would have identified issues quickly. A second opportunity was squandered when 100 percent of certain types of claims suddenly started being denied; this should have raised an internal red flag, but apparently it did not. This type of analysis is the norm for most businesses and industries, and it’s a critical step in maintaining quality assurance and producing positive outcomes. Healthcare billing and claims adjudication should not be any different.

There have been and continue to be unexpected denial surprises. Many appear to center around the unspecified diagnosis code issues. We cannot argue that knowing laterality is a reasonable expectation. However, there are innumerable circumstances in which detailed information may not be available or known and unlisted codes are appropriate. Questions about correct code reporting and clarification abound. WEDI has 45 pages to date, and most listservs are also seeing many questions seeking clarification. As just one example, Georgia Medicaid initially published that no unspecified codes would be accepted as reimbursable services, but it subsequently has corrected that notice to provide additional clarification based on place of service. Some codes that had very specific and/or known policy statements in ICD-9 don’t have comparable codes or policies in ICD-10. These types of questions were sure to arise. Claim denials for previously covered services were a concern, and that concern appears to be justified. Hopefully, these discrepancies can be rapidly resolved with the payors. More importantly, timely coding clarification from authoritative sources is critical. Consistency in applying the authoritative clarification is a worthy goal as we all move toward the robust data reporting ICD-10 provides.

We continue to hear frustration with the right hand not knowing what the left hand is doing in some cases. Calls to contractors and payors posing the same question come away with completely different (and in some cases, contradictory) answers. The transition to ICD-10 was unbelievably complex, with many moving and interrelated parts. As customers, business owners, and managers, such mixed messages are anathema to successful operations. We can and must do better. Although the message may be different from payor to payor, there should be one answer to a given question. It should be accurate and it should be consistent.

By this time next month, we should know where we truly stand as an industry. Final polls should be in. Errata should be published and reprocessing complete. Cash flow impact analysis should be far more accurate, and hopefully, claims and cash disruptions will have been corrected. In the meantime, we should help each other identify and correct problems. Additional education and clarification should be published.

Let’s work together to move beyond war rooms to building the new normal.


Holly Louie, RN, CHBME

Holly is the Compliance Officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho.  Holly is the 2016 President of the Healthcare Billing 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 is a popular guest on Talk Ten Tuesdays.

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