Claims submissions going well, but will payers kick them back later?
The new ICD-10 coding system has been in place for nearly 4 weeks, and so far implementation appears to be proceeding relatively smoothly.
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“We’re not hearing too much in terms of problems practices have encountered, certainly on the front end of the process,” Robert Tennant, senior policy adviser with the Medical Group Management Association (MGMA), in Washington, said in a phone interview. “That means [physicians] have been able to capture the ICD-10 code and submit it on claims.”
The new ICD-10 diagnosis coding system, with its 68,000 codes, is a step up in complexity from the ICD-9 version, with only 13,000 codes. Some experts worried that physician practices wouldn’t be ready to implement the new system when it debuted on Oct. 1, but that doesn’t seem to be an issue thus far.
“I have absolutely no comments from clients — no complaints, no concern about straggling reimbursement, no nothing!” wrote Rosemarie Nelson, a healthcare consultant in Jamesville, N.Y. and columnist for MedPage Today, in an email. “Maybe that is good? Maybe the other shoe will still drop?”
Ginny Martin, director of healthcare practice management consulting at Rehmann Robson in Toledo, Ohio, noted that thanks to a few delays in the implementation of ICD-10, “I think [my clients] were more prepared than they would have been without them.”
“Most had done their homework — made lists of the commonly used codes and cross-walked them to the ICD-10 codes prior to October 1st,” she said in an email. “I think the staff is much more prepared than a lot of physicians — but as long as the staff are knowledgeable, they can go back to their physician and query any additional information they need. Over time, the providers will get it as well (the ones who don’t yet).”
Joette Derricks, MPA, of Derricks Consulting in Ann Arbor, Mich., said that although things are going well overall, Medicare Part B contractors have been listing a few issues on their websites. Some examples:
- “A system error impacted providers who submitted claims for these services in which they reported ICD-10-CM diagnosis code Z23. The system issue has caused these claims to deny in error as having an invalid diagnosis code.”
- “[Name of contractor] has identified a claims processing issue in which claims for the following immunization and administration procedures codes incorrectly denied due to an incorrect diagnosis code. Codes: G0010, G0009, 90630, 90669, 90670, 90732, 90739, 90740, 90743, 90744, 90746, 90747.”
Despite these issues, “Overall it has been positive,” Derricks wrote in an email. “My clients were well prepared with new forms, procedures, and policies. We identified all high-volume diagnoses and it seems like we have about 97% of the ICD-10 codes identified. There [have] not been any productivity slowdowns.”
Chris Zaenger, of Z Management Group, in Elgin, Ill., has noticed one thing: “Payments are dripping in slowly since all of the new ‘Oct. 1 and beyond’ stuff [went into effect],” he said in a phone interview. “Blue Cross is paying in about 5 days so there are no issues with them, but Medicare is slow to come in.”
The ongoing concern now, experts said, is what will happen on the “back end” when the insurers process more of the claims they’ve received. “We are still in limbo in terms of … how claims will be adjudicated,” Tennant said. “Hopefully by end of this week or next week, we will get an idea of how payers are dealing with ICD-10 in terms of granularity.”
He noted that the subject of granularity came up during a panel he moderated a few weeks ago at the MGMA’s annual meeting. “The panel included Humana and [UnitedHealth Group] and both said almost identical things — that things were going smoothly for them, but also that they taken a fairly liberal approach to coding granularity. They weren’t requiring a very granular level of code, but they also said that was not going to last forever.”
“The biggest challenge is going to be seeing how many payers are actually going to leverage their ability to deny services because providers haven’t documented the diagnosis code descriptors in their commentary of [electronic health record] notes, which is required to meet medical necessity,” David Zetter, of Zetter Healthcare Management Consultants in Mechanicsburg, Pa., wrote in an email. “If the diagnosis cannot be deciphered from the notes to match what diagnosis code was billed, then the payer can deny the claim or recoup monies.”
Providers need to be trained for this type of documentation, “which isn’t going to add much more time [to their workload] other than a minute or less in their documentation,” he continued. However, “most providers did not go through this education, and documentation has always been the biggest challenge for providers. [They should] have a look at their line of credit to ensure that there is enough room there should payers start holding claims or taking money back.”
When it comes to Medicare claims, providers need to make sure they really understand the position of the Centers for Medicare and Medicaid Services, said Tennant. Although the general perception was that Medicare was going to be lenient with claims processing as long as the diagnosis code was in the correct coding family — even if it wasn’t exactly the right code — “CMS put two clarifications in that policy.”
“They say the local coverage edits and national coverage edits continue to apply to claim submissions, but the flexibility is on the auditing side,” he explained. “For 12 months, the auditor will not be rejecting a code due to the [lack of] specificity of the code. That’s a very different interpretation to what a lot of folks had.”