HARD REALITY: After many delays, the use of ICD-10 will be mandated for nearly all payers on October 1, 2015. For the first year, CMS will not deny payment on a claim if the ICD-10 code is within the appropriate family. Other payers, however, will deny a claim if the ICD-10 code is not correct. Thus, there remains a real risk that claims will be delayed, denied, or even suspended, resulting in a significant interruption of cash flow.
Over the remaining summer months, providers need to focus on three key areas to ensure ICD-10 readiness:
- Systems Analysis
Perform a final systems analysis to confirm each of the following is ICD-10 ready. Take immediate action to address any identified shortcomings:
- Processes: Scheduling, Check-in/out, Prior Authorizations, Billing, Reimbursement
- Reports: Accounts Receivable (A/R), Physician Quality Reporting System (PQRS), Healthcare Quality Initiative Reports
- Information Systems and Software: Vendor Preparedness, Electronic Health Record (EHR), Practice Management Systems (PMS)
- All Forms of Documentation: Prior Authorization, Referrals, Superbills, Preadmission/Precertification, Order Sets
Failure to resolve even a single issue in advance of the October 1 deadline may cause major disruptions in claims submission and processing that may prove difficult to correct.
- Coding and Documentation
Focus on ensuring as smooth a transition as possible for your coding and billing staff. Consider the following strategies:
- Dual coding: Have coders and/or providers utilize ICD-9 and ICD-10 for a percentage of encounters, and increase the percentage over the upcoming weeks. By the end of September, coders and providers should be coding ICD-10 on 100% of claims. This will allow coders to familiarize themselves with the additional specificity before the effective date. Monitor the coding accuracy, and provide feedback and education as needed.
- Documentation assessment: Identify specific documentation gaps to determine focused education needs of providers. This will be a continuous process, but feedback to healthcare providers is vital to your overall success.
- Preparation for decreased production: Determine if additional staff should be hired, or if portions of your workflow should be outsourced to keep up with the claims volume. Many organizations are outsourcing their ICD-9 coding so that their coding staff can focus on ICD-10. Keep in mind that you will be utilizing both ICD-9 and ICD-10 since claims prior to October 1, 2015, will be coded in ICD-9. Also, those payers not subject to the ICD-10 mandate, including workers compensation and liability insurance companies, still may require ICD-9 coding for a period of time.
- Revenue Cycle and Denials Management
As noted above, CMS recently announced ICD-10 mitigation provisions to help reduce the chance of financial disruptions. Still, providers should not expect commercial payers to follow suit. Therefore, it will be important to prepare for an increase in days in A/R, as well as denials.
Prior to CMS’ announcement, it was estimated that with the ICD-10 implementation, the denial rate would increase between 100% and 200%, and A/R days would extend between 20% and 40%. Depending on your payer mix, these percentages may have changed, but the risk remains real.
Use the upcoming weeks to gain control of your current denials management process.
- Analyze current denials management process: Review how your organization is currently working open claims and denials to ensure they are being processed in a productive and timely manner. This is also the time to ensure that you have the right staff working on appeals. Ideally, personnel who work on denials and appeals are those who go above and beyond and strive for claims and payment accuracy.
- Focus on preventing current denials: Review your top denials to determine if it is possible to create a strategy to prevent them. Strategies to consider include creating edits to catch the claim issue/error prior to submission to the payer and providing education to at-risk departments. The key is to implement processes that will reduce current denials so that you are able to effectively monitor and manage denials related to ICD-10 billing.
It is officially the final countdown to the October 1, ICD-10 deadline. Whether your organization has been proactive in the implementation process, or is in crisis mode, putting your time and attention to these target areas will ensure a smoother post-implementation result.
If your organization requires a boost to prepare for “takeoff” into ICD-10 implementation, PYA’s ICD-10 certified consultants are ready to help with dual coding and denial remediation. If you would like more information about ICD-10 implementation, contact the experts listed below at PYA (800) 270-9629.
