On October 1, 2016, the ICD-10 coding grace period came to an end and physicians are no longer able to submit unspecified codes on certain Medicare claims. With the end of the grace period just behind us, it is too soon to tell whether it has led to an increase in post-payment audits or quality reporting errors, but it has been predicted that one or both of those will happen.
ICD-10 Coding Changes
The organized medical community protested the ICD-10 codes that are more numerous, longer and more exact than the ICD-9 code set they are replacing. The new codes extend to seven characters, with a category code of for the basic condition, followed by four more characters to indicate its etiology, location, and laterality, just to name a few.
CMS has claimed that the new codes will modernize patient care and research and work to prevent billing fraud.
Since October 1, 2015, providers have been given quite a bit of leeway from Centers for Medicare and Medicaid Services (CMS) on their ICD-10 claims. During the grace period, CMS did not reject claims solely on the basis of specificity, but did require claims to include a valid code from the correct ICD-10 family. For example, a claim for chronic gout would have been paid if the physician or coder at least gets the M1A part of the code right, but misses on the cause, body location, or tophus.
CMS Acting Administrator Andy Slavitt wrote a blog post on February 24, 2016, about the early results from the ICD-10 changeover. He noted that “the ICD-10 implementation had all the hallmarks of how CMS could drive a successful implementation and aim for excellence. The approach we took, which has become our doctrine for getting things done, had four major elements.” Those four elements were: (1) be customer focused; (2) be highly collaborative; (3) be responsive and accountable; and (4) be driven by metrics.
He included a chart showing the Final 2015 ICD-10 Claims Dashboard Medicare Fee-for-Service Metrics, as proof of how serious CMS is taking metrics.
Tips to Avoid Claim Denials
The following are some tips for physician practices to prepare and avoid claim denials:
- Be specific. Documentation is used for more than just billing. According to Ann Bina, vice president of compliance fulfillment at West Salem, Wisconsin’s Compliance Specialists, noted that “from a continuity of care and a risk management standpoint, documenting to the highest specificity is in the best interest of all providers.”
- Pay attention to trends in denials. Once we start seeing denial trends, they can be red flags and practices must make sure to keep an eye out for accounts receivable unpaid charges and denials to flag potential issues.
- Emphasize ICD-10 codes that focus on quality initiatives. Rhonda Buckholtz, vice president of strategic development at Salt Lake City’s AAPC, believes that it is particularly vital for practices to discuss and understand how to use codes to the highest level of specificity reporting co-morbid conditions when necessary for patients with complex care needs.