January 25, 2016

Unspecified Codes among Issues Being Monitored


Jill Finn

Ana Croxton

At the four-month mark of ICD-10 implementation, practice management vendors are continuing to look for trends and potential issues for their clients. Several things currently being tracked are the overutilization of unspecified codes, claim submission, and payment productivity – and whether payers have implemented some, part, or all of the ICD-10 edits that will impact the financial health of providers. HATA members AdvancedMD and NextGen currently are mining their data and hoping to work with payers to achieve continued success with ICD-10.

At AdvancedMD, we’re continuing to encourage clients to familiarize themselves with coding standards, to understand the clinical situations that are expected to generate documentation with the highest level of specificity, and to have processes in place to ensure that they remain compliant with these standards.

We’re still expecting that as carriers start getting into a rhythm of adjudication over the next few months, the rules will tighten up, meaning that overutilization could result in large spikes in costly denials across the board. We’re happy to see that our data so far is showing that clients are listening. Under ICD-9, in an average month we were seeing unspecified codes being used around 32 percent of the time. Under ICD-10, we’re seeing a rate of about 22 percent, which is very encouraging because it shows that our providers are being mindful of how they’re coding.  

Another area we’re tracking is the impact that ICD-10 has had on our billing service and providers, particularly in the amount of time they’re spending on coding and charting. In 2014, the American Medical Association (AMA) initiated a cost study that estimated the overall implementation cost for the ICD-10 transition. The two most pressing areas of concern for us were lowered productivity and payment disruption. The study estimated that a small physician practice could experience a 10-percent loss of productivity and a 15-percent increase in documentation time.

As we planned for ICD-10, our belief was that if we built tools to help physicians code to the correct level of specificity, they could avoid a major revenue loss after the transition. To address this, we put robust diagnosis search and mapping tools in place across our product lines to allow physicians to get to the correct code before leaving the exam room (and to alleviate work for the billers, prevent denials, and ensure that charts notes align with the coding). We’re currently gathering data on the amount of time it is taking to process and pay claims in order to see how our clients are doing compared to the estimates. and we will share that data in the near future.

While we’re moving forward with cautious optimism and keeping ourselves and our customers aware of potential issues and how to avoid them, we of course also want to continue celebrating the great success that we’ve experienced throughout the transition so far. 

At AdvancedMD we’ve been able to move into maintenance mode with our ICD-10 response team, wherein rather than meeting twice daily, they’re now monitoring automated reports to identify anomalies and provide proactive assistance to clients where needed. We’ve also discontinued our weekly webinar series as clients have gotten comfortable with ICD-10 and the attendance declined. All in all, we fully expect continued success as we move forward, but we’re trying not to get too comfortable just yet.

Much like AdvancedMD, NextGen planned a comprehensive education package along with changes to the application to meet ICD-10-related needs. The feedback from clients has been overwhelmingly positive, both in regard to the impact that ICD-10 has had on them and the support they received from us. Some of the positive support and education included:

  • A ICD-10 webinar series, including clinical calls by specialty
  • Weekly webinars for practice management claims configuration
  • Free ICD-9/ICD-10 Web training and educational tools
  • ICD-10 boot camps
  • Participated in HIMSS/WEDI end-to-end testing
  • Coding services
  • E-learning courses to train and educate client staff and physicians

We worked closely with our clients and offered end-to-end testing, allowing them to gain a comfort factor. After the clients were able to see the process work, from claim generation to claim acknowledgment to electronic remittance advice, it reduced some of the apprehension; you could say it demystified the implementation.

In an effort to minimize the impact to our providers’ productivity and ensure that their clinical documentation supported ICD-10, we analyzed the ICD-10 code set and added the appropriate fields into the application to capture the necessary data. Providers were able to begin using this intelligence prior to the implementation date. As a result, our providers today are demonstrating confidence with their documentation and knowledge of the ICD-10 codes. 

We’ve had some isolated issues reported; one example was a situation in which we had to disable the quality codes edit for anesthesia claims because the Centers for Medicare & Medicaid Services (CMS) no longer requires them. So far we haven't seen any massive changes from the payers, and that actually could be cause for concern.

Having been told “off the record” by several payers that they have not activated all of what will be the normal “ICD-10 edits,” it has become clear that it could be difficult to determine success if the full processes are not in place – and this likely will happen in drips and drabs, making it harder on all of us.

We encourage providers to be mindful of this and to pay close attention to denials (new denials in particular), and to perform the appropriate follow-up to find a resolution quickly. This is where vendors can continue to play an educational and supporting role for our clients.

I would say the initial implementation of ICD-10 was a great success. Now we have to see this through to a full-blown cycle and begin to gather data on the benefits.

Jill Finn

Jill Finn is the Information Technology Release Manager at ADP AdvancedMD. She has more than 10 years of experience in the healthcare IT industry, leading teams to success across a diverse range of products, including practice management, revenue cycle management and human capital management. She is a board member of the Healthcare Administrative Technology Association (HATA) and served on the Advisory Committee for the Practice Management System Accreditation Program (PMSAP) led by EHNAC and WEDI.

Related Stories

  • Making the Case for Good Auditing
    In this article, the author gives a shout-out to auditors for the good work they do. For those of you who are CEOs, CFOs, medical directors, etc., I would like you to take a moment and read the excerpt below,…
  • We are Now in an ICD-10 World – But is Data Better?
    Unfortunately, the quality of data is driven less by opportunity and more by incentives for those creating the data.Prior to the implementation of ICD-10, the key selling point of the new coding set was that it provided the opportunity for…
  • CDI and Medical Necessity: Closing the Gap Could Prevent Denials
    Medical policies are based off of evidence-based medicine. Without proper documentation, however, most providers struggle to get services or procedures covered for patients.Exactly what is medical necessity? To many, it is the belief that a service or procedure is warranted…