HMT: Six months in, does it look like providers were ready for the ICD-10 launch?
Slight: Overall, yes. Most hospital provider clients made efforts to provide ICD-10 education to prep physicians for the increased specificity through clinical documentation improvement (CDI), which helped with the transition. Many Nuance hospital clients took full advantage of our ICD-10 coding boot camps prior to implementation to give coders a basic foundation to code in ICD-10, which definitely helped prepare for the transition and cushion the initial coding productivity loss. We also found that clients who took advantage of our data analytics were better prepared from a coding and clinical documentation perspective.
Since ICD-10 took effect, Nuance Clintegrity coding clients have indicated an increased number of provider clarifications – but over time. These types of coder clarifications will decline as long as coders continue advanced procedure coding system (PCS) education.
Non-acute care providers – clinics, offices, specialists, etc. – were also well prepared for the ICD-10 implementation in their office setting. We have heard reports of various types of failures such as EHR failure, outsourced vendor failure, billing software failure, and clearinghouse issues. While these failures have not been widespread, the impact has been significant for the affected parties.
Shrader: For the most part, providers and insurance companies were ready for ICD-10. While there have been denials related to the new diagnosis codes, the transition has been better than most would have expected.
Endicott: Yes. Implementation seems to have gone seamlessly. I have heard very positive feedback about the relative ease of transition. There should be ongoing provider education to ensure that the most complete documentation is being entered in the health record. This not only enables accurate code assignment, but also ensures quality care of the patient.
HMT: Do you expect claims denial rates will rise once CMS demands more specificity in terms of coding and stops accepting older codes? What can providers do to prepare themselves for the extra scrutiny? Or are we in for another delay?
Slight: There will likely be increased claims denial rates once the CMS ruling expires on Oct. 1. In advance of this, providers should continue to educate, audit, and reinforce the need for appropriate specificity in all appropriate codes. It’s important to get in the habit of documenting and coding in full specificity today – specificity is already a critical component of the revenue cycle for documenting, coding, and reporting outcomes.
We have not heard reports about a potential delay in the CMS enforcement of specified codes.
Shrader: Denial rates will rise for providers who are not keeping current with Medicare and insurance payer policies. Providers will need to review chargemasters for invalid CPT/HCPCS and revenue codes. Continuing education and identifying the denials early on is key to addressing the diagnosis and coding errors.
Endicott: It’s possible we will see an increase in denial rates, but providers have been and should continue to have complete documentation to ensure that the most accurate codes are assigned. The more specificity, the better! An ideal way to help capture more complete documentation is through focused education for professionals within the organization who view the documentation daily.
Slight: While there doesn’t appear to be a significant increase in denials, we are starting to hear that denials are starting to creep up a bit. One Clintegrity coding client reported about one denial per month, citing “invalid code” when they had submitted a correct and valid code. Initially, there were some reported issues with medical necessity determination and edits that affected certain provider specialties.
Facilities and providers should closely monitor and track all claims denials and determine appropriate action on a case-by-case – and timely – basis to ensure the denial rate does not significantly increase in the next six to 12 months, resulting in lost revenue.
Shrader: It will take a team effort to reduce denials. Healthcare organizations with strong scrubbers can help keep claims clean, including identifying and removing rogue characters. The payer community also bears some of the responsibility to make sure their computer systems remain flexible.
HMT: In general, is revenue increasing since the adoption of ICD-10? If so, can the new coding structure be credited for that?
Slight: Improved documentation will certainly have a positive impact on severity, outcomes, and, in some instances, case mix. This is especially true if these are impacting revenue, SOI, or ROM. Some CDI clients have already seen that better documentation – including specificity on billing codes – helps better reflect the care delivered, which leads to both clinical and financial benefits for organizations.
Shrader: Revenue is not and will not increase as a result of the specificity of the codes. With the increasing level of detail, procedures are grouped in a greater degree of acuity. But, as was the situation with ICD-9, diagnosis will not move to a higher level of reimbursement.
HMT: What steps can providers take to make sure they’re analyzing their claim denials and spotting trends and problem areas?
Slight: Track, track, track! It’s so important to track various key performance indicators (KPIs) pre- and post-ICD-10 implementation – such as days to payment, days to final bill, claims denial rates, and coder productivity – to find any differences, analyze them, and determine the root cause for negative findings. We always recommend using an external coding auditor to validate coding accuracy, claim submission, and clinical documentation improvement opportunities. Following any type of audit services, the organization should always receive a comprehensive report including coding accuracy rate, documentation completeness for ICD-10, and rate of unspecified code usage.
Shrader: First, providers need to ask: Does my procedure meet medical necessity? If not, then they should review for the appropriate diagnosis. Second, providers need to review their payer denials by denial code to identify trends to correct. Third, they should offer ongoing education for practitioners and hospital providers. Finally, providers should have a strong review team and processes to identify potential denials.
Endicott: Providers should have a dedicated professional review the claims denials to look for trends and to analyze whether the denials are due to documentation gaps or coding errors.
HMT: Is there any evidence that private insurers are denying patients coverage more often after the ICD-10 implementation?
Slight: The recent February Healthcare Billing and Management Association (HBMA) survey suggests an increase in the number of private payor denials.
Shrader: It is too soon to tell. However, private insurers have policies in place related to timeliness of filing – some companies require a clean claim to be filed in 30 days or less, whereas Medicare and Medicaid are normally 365 days for a clean claim to be filed. This shorter timeframe, combined with the complexity of ICD-10, could lead to more denials.
HMT: Is there a discrepancy between what’s expected from a claim processed by Medicare and Medicaid, as opposed to a private insurer?
Slight: Each state Medicaid program and private payer is able to set their own claims processing rules. These may or may not correlate to CMS requirements.
Shrader: It all depends on the contract with the private insurance company, which can affect authorizations, limits on treatment options, requests for additional inpatient treatment days, additional clinical documentation, or review by the provider and the insurance company. For example, some insurance companies require that an insurance authorization be obtained within 24 hours of the private insurance patient being seen in the emergency department, but that is not the case with Medicare and Medicaid.
HMT: Are small practices showing the same level of success as larger healthcare systems?
Slight: We have not heard of discrepancies based on healthcare system size, although there are reported differences based on specialties. Anesthesia, primary care, and radiology experienced more problems than emergency medicine, pathology, or oncology – which reported no problems. These differences appear to be more related to medical necessity issues for certain types of services rather than size of provider practices.
Shrader: Smaller practices, which may deal in fewer diagnoses of illnesses, should have fewer items to focus on, but accuracy is extremely important for them. Larger systems are going to face some issues with providing the additional details to identify the diagnosis.
Slight: Providers are already able to reap the benefits of the additional documentation available when providing follow-up care to their patients. Some CDI clients have already seen that better documentation helps better reflect the care delivered, which leads to both clinical and financial benefits for organizations.
Once we have a full year of ICD-10 data, we’ll be able to have a better understanding of the benefits. However, it may be a year or longer before we see benefits from additional claims specificity, such as a reduction in requests for medical records from payors.
Shrader: Yes, it will as we make progress toward population health and clinical predictive analytics. Identifying the best treatment options for a patient, or similar group of patients, should lead to improved clinical care.
Endicott: Anecdotally, I would say the ICD-10 coding structure is helping physicians to get more information about their patients. I haven’t seen any reports on this yet, but with the increased specificity of ICD-10, one of the benefits is improved patient care.
Belley: If physicians take advantage of ICD-10’s specificity when documenting their patients’ diagnoses and conditions, there is no question the more precise documentation will reap benefits. One example is documenting for hierarchical condition categories (HCCs). HCCs are used by CMS to determine reimbursement of Medicare Advantage Plans for their costs in treating patients within a population. We’re also seeing increasing adoption of HCCs by commercial payers; so they are becoming a key focus for many healthcare organizations. HCCs identify diagnoses present in the patient that complicate their care and require more resources to treat. The sicker the patient, as indicated by an HCC, the more expenses that might be incurred – so reporting of HCCs impacts the per-member per-month payment from CMS or a commercial payer.
To be paid accurately under HCCs, physicians must specifically document the disease burdens of their patients. One example is hepatitis C. Many physicians simply document “hepatitis C” in the patient’s medical record when their patients actually may have chronic hepatitis C. Chronic hepatitis C is considered an HCC, whereas hepatitis C with no further description is not. In failing to document this additional specificity, neither the disease burden of the patient nor the extra dollars needed to care for this patient are recognized. This will impact reimbursement. ICD-10’s coding structure makes it possible to document disease burden and be paid appropriately under HCCs. This is just one example of the benefits to be gained from ICD-10.
HMT: In the end, did all of those crazy ICD-10 codes we kept hearing about really muddy the waters for providers?
Slight: The so-called “crazy” codes fall under Chapter 20, External Causes of Morbidity (CM), which have little impact to providers outside of emergency department settings. Unless a provider is subject to a state-based external-cause code reporting mandate, or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20 is not required of the patient at the time of the event, and the person’s status.
Shrader: The waters are muddied because reimbursement is attached to the ICD codes. The United States is the only country to correlate ICD codes with reimbursement. The original purpose of ICD was to group specific diseases or ailments. In ICD-9, diseases could be more general with less specificity.
Belley: No, all those “crazy codes” did not muddy the waters for physician providers. Codes such as being “pecked by a turkey” were often bandied about in news articles, but what got lost in the media coverage is that physicians are not required to report these codes. While some states may require that hospitals report “external-cause codes” as they are called, there is no national reporting requirement, and either way, it doesn’t impact physicians. External-cause codes describe how injuries are sustained by a patient. These kinds of codes appeared in ICD-9 as well. Most providers never had to use ICD-9-CM code E845, accident involving spacecraft, but that didn’t impact their ability to use ICD-9.
External-cause codes may seem amusing and unnecessary, but they can be very important for public health initiatives. For example, a lot of turkeys died or had to be destroyed in 2015 due to avian flu. Although very rare, turkey-to-human transmission of avian flu is possible. Thanks to the new ICD-10 codes, the CDC can quickly identify, track, and monitor potential disease outbreaks as a result of coming into contact with a turkey.
HMT: When do you think we’ll start hearing rumblings of ICD-11?
Slight: ICD-11 is now being developed through a continuous revision process through the World Health Organization (WHO) and is scheduled to be finalized in 2018. The U.S. will then need to develop the clinical modification version to meet U.S. specific reimbursement and reporting needs; therefore, ICD-11-CM for the U.S. is still several years – if not many years – away from release.
Shrader: ICD-11 will have to wait until we fully understand ICD-10, which has taken our focus for the last five years.
Endicott: The WHO website says ICD-11 is due by 2018. Keep in mind that this is the WHO version, and the U.S. must modify it for our particular needs, which will take at least 10 years.
Belley: Keep in mind that, after the WHO released ICD-10 in the mid-90s, it took the United States nearly 20 years to adopt it as the national coding standard. Before ICD-10 could be implemented, the diagnosis codes had to be modified and procedure codes had to be created for use in this country. Then there were lengthy industry comment periods before and after CMS initiated the rule-making process. Once the final ICD-10 rule was published in 2009, it took six years for Congress to legislate ICD-10 adoption and establish an official start date – after three delays! I think we can expect a good long time before the U.S. is ready to move to ICD-11, especially if we follow a similar path to what we did with ICD-10.
