MLR

Ready or not – ICD-10 is here

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Like many practices, yours may be facing lost productivity as a result of the learning curve or lack of preparedness for the conversion to ICD-10. Claim rejections or delays in payment in some cases may jeopardize healthy cash flow during these first few months.

worried doctor

The good news is that Medicare fee-for-service Part B claims will be processed and not audited through Sept. 30, 2016. Medicare will accept unspecified codes for this one-year grace period. The one-year transition period brokered by the American Medical Association with the Centers for Medicare & Medicaid Services (CMS) should help to mitigate potential problems arising from coding errors related to granularity or system glitches.

This flexibility extends to penalties related to the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) or the Meaningful Use (MU) program.

The bad news is that the grace period is for traditional Medicare claims only. It does not extend to Medicaid, Medicare Advantage or other claims.

Speaking at a webinar sponsored by ZirMed, Inc., a cloud-based financial and clinical performance management company, Elizabeth Woodcock, MBA, FACMPE, CPC, noted that practices with a lot of evaluation and management (E/M) claims should be sheltered from the storm of denials versus those with a higher volume of claims for procedures.

Actions to take now

Practices should address implementation problems as quickly as possible to help mitigate negative impacts:

  • Experts suggest creating a process – if one is not already in place – for monitoring pended/rejected claims and those with no response. Woodcock suggests analyzing denials by type, ICD-10 code and category, medical necessity, dollar amount, date, payer, physician, etc.
  • Tracking the reasons for nonpayment can help determine patterns that can then be addressed. If the problem lies in documentation, which physicians are not thoroughly documenting medical records? Are coders capturing all of the information needed? Is there a problem with the vendor or a particular payer? Some experts have suggested holding claims of a vendor’s or payer’s system experiencing glitches until the issues are resolved.
  • Woodcock recommends holding a weekly morning huddle to discuss the analytic results and to disseminate a weekly scorecard that identifies the issues.
  • Practices can apply for an advance payment from Medicare if Part B claims cannot be processed within certain time limits due to a Medicare contractor’s system malfunction or implementation problem. This partial payment must be repaid once the system is processing properly. If your MAC’s system is the problem, check their website for more information and instructions on applying for the payment.
  • Try to determine where the bottlenecks are to improve productivity. Some loss of productivity is inevitable in terms of both initial coding and rework. It may be that additional coding assistance is needed to speed up claim submissions either through temporary staff or a third-party billing company.
  • For practices overwhelmed with denials, Woodcock suggests determining how many denials the practice can handle in one day and compare that number to the number of inbound denials per day. This method can help determine the practice’s needs in terms of personnel to rework those claims.
  • Rejected claims, payment delays, loss of productivity and additional hiring requirements can wreak havoc on cash flow. Tapping a line of credit to cover operational expenses during the initial ICD-10 implementation period may be required should all else fail.
  • Just because the Oct. 1 implementation date is past doesn’t mean training should halt. Continue efforts to educate and train staff as needed.

All in the family

Medicare fee-for-service Part B claims will be paid if a valid code in the proper family is provided. The first three characters, which refer to the general disease, must be correct, even if those that follow are not.

As an example, C81 is the family code for Hodgkin’s lymphoma, but it is not a valid code by itself. Valid codes for Hodgkin’s lymphoma include C81.00, C81.03, C81.10 or C81.90. Any one of them would be acceptable on a claim for Hodgkin’s lymphoma through Sept. 30, 2016. So, if the correct code is C81.03, but the code submitted is C81.00, the claim would be paid because it is a valid code in the correct family.

Note that coding specificity required by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) continue to be required under ICD-10. Claims submitted must include the full number of characters required for a code, including the seventh character, if applicable.

Help is available

CMS has established an ombudsman’s office headed by William Rogers, M.D., in its ICD-10 Coordination Center in Baltimore. The ombudsman will triage issues and work with representatives in CMS’s regional offices to address physicians’ concerns. To submit issues to the ombudsman’s office, send an email to icd10_ombudsman@cms.hhs.gov.

In addition, a complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. Codes are listed in tabular order as in the ICD-10-CM code book. – Irene E. Lombardo