Life Science Compliance Update

December 07, 2016

Tips for Avoiding Claim Denials Related to ICD-10


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.

Slavitt’s Take

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:

  1. 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.”
  2. 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.
  3. 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.

October 21, 2016

Post ICD-10 Changes to the ACA and its Implications


The coming year will bring along change for practices. The ending of the ICD-10 grace period will bring rising problems for practices if they are not prepared. Apart from nearly 2700 new codes that are coming out, there are also significant changes in old codes as well.

With the introduction of ICD-10 it was decided that there would be a year’s time where all unspecified codes would still be accepted and not sent into denials mostly because many practices were unprepared. With this changing, the denials rates of practices will be rising to a huge extent. To combat this, practices need to have a medical billing software which is well equipped with the recent changes and the updates.

It is predicted by many experts that the denial rates will be moderately higher for practices come October 1st, however, they will be significantly higher for practices that do not have medical billing software, and are not prepared. Of course, the full wrath of the changes will be felt differently, depending upon which family of codes a particular practice gets often. Hence it is important to see the relevant changes concerning your practice, and then deciding what is needed.

The problem is that a relatively small practice will need such software much more, because it is harder for a smaller practice to hire an entire billing department, and hence in some cases (learn more) the doctor himself/herself ends up doing the coding, which basically results in a couple of extra hours every day. Instead, this time can be utilized in taking care of more patients which can result in not only a higher profit for the practice but better care for the patient. This way it all comes down to specialization, the doctor should be doing what the doctor knows best, which is to practice, and the coder should do what the coder knows best, which is to code. Now when the doctor takes the time to start doing other tasks ultimately it is a waste of resources.

The changes and the new codes that are being introduced are very important, and one should be fully prepared not just for the updates of the ICD-10, but for other factors that will be affecting the medical industry in the long run. One of these things is the upcoming election, which will have major implications on healthcare. The healthcare industry was revolutionized with the “Affordable Healthcare Act,” (ACA) ever since it became part of the constitution. Similarly, with the front runners of the both the major parties decided it would be interesting to see what potential effects they will have on the healthcare industry in the foreseeable future.

Hillary Clinton has exclaimed that she would not be for repealing the affordable health care act and actively “defend” it and even build on its success, whereas Donald Trump wants to completely repeal the act, and instead bring in “something great.” Now basically what does this mean for the healthcare industry, will the upcoming elections bring about a paradigm shift, and change the way things are done entirely?

    Now changes to the ACA look likely whether Clinton or Trump take the white house; however, this could be harder to do especially since the Supreme Court upheld it in 2012 and it is firmly a law of the land. It is estimated by the Obama administration that it would add around $137 billion to the federal budget to repeal the ACA.

Below we will be discussing the federal health care plans of both major party candidates, although neither candidate has outlined a detailed comprehensive plan as far as health care is concerned, they have suggested certain policies which provide a generic outline on which we can make an analysis.

Recently at the DNC Hillary Clinton talked about how she wants to defend and further add changes to the ACA to make sure that affordable health care is provided to as many Americans as possible. She also talked about how she would protect Roe v. Wade which was a landmark decision as far as abortion is concerned. As far as Clinton is concerned it should be protected and the decision of abortion should clearly lie with the mother.

Mike Pence who is Donald Trump’s running mate, actually talked about putting Roe v. Wade to the ash heap of history where it belongs. The republicans are pro-life, and would repeal the aforementioned case which would mean a huge tassel in congress.

Now here is the direct impact that the industry will have as far as practicing doctors are concerned. A Hillary Clinton presidency brings more of the same thing in a bigger package, more regulations such as HIPPA and HITECH in the industry, which means that practicing doctors will be treating more patients, relatively be getting paid the same amount that they are being paid currently with adjustments to inflation of course.

A Donald Trump Presidency would bring with it free market conditions, that could considerably increase the pay of doctors, and bring with it fewer regulations in the long term. This could lead to fewer people have access to good healthcare who cannot afford it; such is the law of the market. 

However whichever candidate gets selected, it is important to keep track of what is important, and for a practice, the most important factor should be how to keep afloat and turn in profit while helping the most amounts of people. To do this the practice needs to update about the changes that are coming, especially with the ICD-10 grace period ending.

Author Bio: Aiden Spencer is a health IT researcher and writer at CureMD who focuses on various engaging and informative topics related to the health IT industry. He loves to research and write about topics such as Affordable Care Act, electronic health records, Medical Practice management and patient health data. You can get in touch with him on Twitter: @AidenSpencer15

September 30, 2015

ICD-10 Transition Begins Tomorrow, October 1


The time is finally here. After delays and much deliberation between government and physicians, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This goes into effect tomorrow, October 1, 2015.

 ICD-10 basics

ICD-10 stands for the International Classification of Diseases, version 10. It is a coding system that attaches a number for every disease of trauma known to the medical world. According to the World Health Organization, ICD is “the standard diagnostic tool for epidemiology, health management, and clinical purposes.  It is used to monitor the incidence and prevalence of diseases, providing a picture of the general health situation of countries.”  In the U.S., the ICD has been adapted for billing. While work on ICD-10 started in 1983, HHS used ICD-9 until 2013 and was subsequently delayed twice by Congress. ICD-11 only exists in draft form and is not expected until 2020 or 2025.

Physician concerns

As we previously wrote, the U.S. has lagged behind other countries in updating to ICD-10, but the process is by no means a quick fix. The number of procedural and diagnostic codes is estimated to increase from about 17,000 unique codes in ICD-9 to over 140,000 unique codes in ICD-10. A procedure like an angioplasty, for example, will shift from having 1 code to having 854 possible codes, according to reporting done by MedPage Today.

Physicians are concerned the new system will cause additional administrative burdens with new documentation requirements that, if incorrectly applied, could result in denied claims (See Kevin MD). In fact, an August survey by Navicure/Porter Research shows that an "overwhelming majority (94%) of participants" anticipate an immediate increase in their denial rate, with 56% of respondents citing ICD-10's impact on revenue and cash flow as their top concern. Practice administrators and billing managers comprised the majority of survey respondents (58%), followed by practice executives (14%) and billers and coders (14%). While survey respondents represent a range of specialties and sizes, two-thirds (67%) are from organizations with one to 10 providers.

Some flexibility issued by CMS

In July, CMS announced that it would provide greater flexibility during the transition to ICD-10 billing codes. Specifically, while diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation date, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. Starting October 1, 2015, however, CMS will require a valid ICD-10 code.

CMS addressed its interpretation of “family of codes” in a recent document, saying the codes are the same as the ICD-10 three-character category. CMS writes: “Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.”

“Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid."

CMS remains fully committed to ICD-10

“As we work to modernize our nation’s health care infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” said Andy Slavitt, Acting Administrator of CMS this July.

“With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.”

In a recent Q&A document, CMS outlined answers to several common ICD-10 questions. The agency writes that it “understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.”

Politico reports CMS contingency plans

According to Politico, CMS has plans in place depending on the scenarios that could take place during the transition to ICD-10. Politico writes the five specific CMS contingency scenarios include: (1) CMS’s systems are working fine, but providers have an inability to submit any codes; (2) Providers are submitting ICD-10 codes, but incorrect ones; (3) CMS’s systems are not working correctly; (4) There is an additional delay to ICD-10; and/or (5) There are problems with submitting claims unrelated to ICD-10. If Medicare systems are not working properly, CMS will hold claims while issues are resolved. If providers are having issues, the agency will remind providers of their options including submitting paper claims. You can read more at Politico’s website on the contingency plans (subscription required).

Some helpful tips

The advice from those who have already tried coding with ICD-10?

Hire a certified coder if you do not have one on staff already. Other recommendations include scaling back on the number of patient visits booked in October, giving physicians extra time to learn and incorporate ICD-10. Additionally, experts suggest a focused approach to learning the codes to help avoid becoming overwhelmed. Take the top 100 ICD-9 codes and become familiar with their ICD-10 version. Finally, thorough documentation will be a critical step to make a smooth transition into ICD-10 coding.



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