8 steps to better reimbursement with ICD-10

When the International Classification of Diseases, Tenth Edition (ICD-10) clinical cataloging system went into effect for the U.S. healthcare industry on October 1, 2015, it reflected modern advances in clinical treatment and medical devices. It also caught the U.S. up with 100 other countries already using the system, which was first adopted by the World Health Organization (WHO) in 1990.

Despite the need for the ICD update, U.S. healthcare providers approached last year’s ICD-10 implementation worried that the exponential increase in diagnostic codes (from 13,000 to more than 68,000) would lead to more errors in medical claims and ultimately denials due to the new specificity required, including age- and gender-related codes. Adding to this detail, there are nearly 5 times more classification options with ICD-10 when compared to its predecessor, ICD-9.

ICD-10 reimbursement tipsTo help ease the transition, a year-long grace period was established by the Centers for Medicare and Medicaid Services (CMS) allowing flexibility for the purpose of contractors performing medical review. Claims would not be denied solely for the specificity of the ICD-10 code, and they would be accepted as long as they were submitted in the right family of codes. The grace period only applied to claims submitted to Medicare and Medicaid. While many commercial insurers offered similar flexibility, the majority did not.

What this means

While providers will still be allowed to use unspecified codes when they are warranted, the CMS stated that these should be the exception, rather than the rule. Submitting unspecified ICD-10 codes could lead to an increase in claims rejections, payer requests for medical records and clinical documentation, and increased demand on staff as they handle Medicare audit requests for medical records.

If that weren’t enough to keep up with, roughly 1,900 diagnosis codes were added to the ICD-10 coding system for healthcare claims, and some 3,651 new ICD-10 inpatient procedure codes for fiscal year 2017 were also added. This updated diagnosis code set for services provided on or after October 1, 2016 is called 2017 ICD-10-CM (clinical modification).

Despite these changes, there’s no need to panic. Following these 8 steps can help improve your business practices now that the grace period is over:

  • Arm yourself with the proper tools: Make sure the electronic health record (EHR) you choose helps you accurately document your patient visits, regularly updates the new codes through a cloud-based platform as they are released by the Centers for Disease Control and Prevention, and provides filters that help you diagnose common mistakes before billing.
  • Slow down: Look for the most specific code you can find in your EHR menu (don’t be too general) and make sure the coding on the claim aligns with the clinical documentation.
  • Code appropriately: While some cases of unspecified codes are acceptable and even necessary, you should code each healthcare encounter to the level of certainty known.
  • Monitor yourself: Frequently run reports to track your practice’s most common diagnoses. If the codes for these diagnoses tend to be unspecified, it should be a signal for you to look for ways to improve your process.
  • Compare denial rates: Compare your current denial rates with the same month during the previous year to see if there was an increase in denials, then work to understand why.
  • Avoid audits: To reduce scrutiny, make sure your documented diagnosis matches the ICD-10 code selected.
  • Add support: Consider hiring a Certified Professional Coder (CPC) who will have mastered the intricacies of ICD-10 and other terminology and who can be the authority for your practice.
  • Check it: For ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website.

A reliable EHR will help practices adapt to ICD-10 changes by notifying physicians immediately if they do not have the appropriate coding, saving the practices time by not having to correct it later. This also avoids the risk of a claim being rejected and slowing down the revenue cycle. Should the practice ever have to go through an audit, having the right EHR ensures that the medical record documentation needed is there to back up the code that was used. The right EHR provider will also give your practice the support it needs to navigate the constantly changing healthcare landscape.


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Sources: CMS, Healthcare Informatics, Healthcare IT News, TechTarget, Medical Economics


ICD-10 reimbursement tips

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