Accruing ICD-10 Benefits Requires Planning
Valerie Rinkle, Associate Director with Navigant Consulting, Agility Advisory Board Member
Perform a Google Search on “ICD-10 benefits” and you will get a plethora of sites with slides, white papers and blog postings, including CMS.gov materials. What are less prevalent are articles that take any one of these benefits and step through a logical sequence of why or how the benefit will accrue to providers, payers, government or the healthcare marketplace. It is important to ask why and how such benefits could accrue. Thoughtfully and logically thinking these issues through will help to inform the sequence of events likely to play out in the short, medium and long term with the ICD-10 transition. It is important that this perspective inform organizations’ strategic plans and efforts, particularly as they strive towards lower cost and more streamlined operations.
Among the most significant benefits touted with ICD-10 include:
- Improved reporting of diagnoses and procedures
- Improved analytics regarding outcomes
- Fewer claim rejections and/or medical record requests prior to claim adjudication
- Diminished need for record abstracting to meet information requirements for quality reporting
ICD-10 provides for significantly improved specificity in coding clinical conditions, external cause of injury, approach and type of procedures and devices, adverse events and after effects. For example, in the area of occupational medicine, many payers require the current supplemental ICD-9 diagnosis code of V62.1 defined as “adverse effects of the work environment.” In ICD-10, there are 11 specific qualifying supplemental diagnoses encompassing exposure to noise, dust, and vibration to name a few. In order for ICD-10 to capture the granular data and information, the medical record must contain the detail to support the code(s).
There are four basic pathways for codes to be assigned to a particular patient encounter: (1) the medical record documentation is read and interpreted by a trained coder who assigns the codes; (2) the clinician selects codes from various drop down lists or reference tools or directly enters codes via the EHR or other job aids such as a superbill; (3) natural language processing or computer assisted coding programs integrated with some software programs that will propose codes based on terminology in the documentation and (4) any combination thereof. However, none of the benefits of ICD-10 can accrue unless the underlying medical record documentation exists and the pathway for assigning codes is adjusted to capture the increased specificity. At the root of the ICD-10 transition is the need to transform documentation to capture the necessary concepts such that the more specific codes can be captured to the greatest detail and in the most efficient manner possible. It is very important that each clinician understand the pathways deployed to produce ICD codes for their encounters and documentation.
If not already done, now is the time to look at the top diagnosis codes by patient and payer type. Cross walk these codes to their ICD-10 codes. For example, here are the top 3 ICD-10 diagnoses for Urgent Care: 1) J01.90 Acute sinusitis 2) JO2.8 Acute pharyngitis 3) JO6.9 Acute upper respiratory infection. Consider if there are any new concepts included in the ICD-10 codes. What additional detail is captured by the code options? Are any of the new concepts or detail helpful to clinical communication and coordination for patient care? Do any of the new concepts better explain risk of mortality or morbidity? The answers to these questions will help inform providers about necessary modifications to prompts and pathways that will help to optimize documentation and support/capture of the new codes.
Another likely scenario regarding ICD-10 is stricter and limited payer coverage policies. For example, if a patient presents with abdominal pain to urgent care and the claim for that encounter has a primary diagnosis of “unspecified abdominal pain,” is the payer likely to cover the ultrasound and lab tests performed on a female patient of childbearing years? Most practitioners are adept at ruling out a potential ectopic pregnancy. However, doing so entails lab tests and possibly an ultrasound in addition to their Evaluation and Management (E/M) service. If the primary diagnosis is abdominal pain “unspecified” it seems to the payer looking at the claim data only as if these services were provided on a whim, with very little detailed medical decision making on the part of the ordering practitioner. This is not likely true, but a claim submitted with this primary diagnosis imparts this impression. So this incidence invites investigation. What is the pathway for the codes to be selected and populated on the claims? Can the organization “afford” the possibility of claim denials and rejections if it has a high proportion of codes that are “unspecified?” Has your organization performed an analysis to determine whether there is frequent use of unspecified codes and for what service lines?
Providers and healthcare organizations will be measured and publically rated based on the ICD-10 codes on claims. What patient registries or qualifiers or quality reporting is currently produced with ICD-9 codes today? What changes are needed with appropriate ICD-10 codes?
Consider what claim denials occur today based on ICD-9 codes. How can this be mitigated now to prepare for ICD-10? Are there significant ICD-10 code concepts that change for high volume patients treated in the practice? Search now for the Medicare Administrative Contractor (MAC) coverage rules that include ICD-10 codes. Are there changes needed to how services are documented, ordered, coded or provided because of the ICD-10 codes included or excluded from the coverage policies?
Thinking through the implications of the benefits various entities expect from ICD-10 requires a very thorough flow of the pathways codes are assigned and the potential documentation vulnerabilities. Think through the touted benefits of ICD-10 from the payer, provider, and quality reporting and coverage/claim denial perspectives for the main services and patients served. Ensure that plans are in place that will effectively ensure benefits are realized by advance preparation.
About the Author:
Valerie Rinkle, MPA, is an Associate Director with Navigant Consulting and has more than 30 years of experience in healthcare finance, strategy, and operations. Her expertise spans all CMS reimbursement methodologies and the operational capabilities necessary to effectively achieve accurate and defensible payment. She is an acknowledged expert on the hospital Outpatient Prospective Payment System (OPPS) and has extensive hospital chargemaster experience with the major hospital accounts receivable systems (Epic, Cerner, Meditech). Valerie is able to respond to evolving reimbursement policies as well as newer methodologies such as bundled payment, ACOs, HCCs, provider-based clinics, merged facility, and professional patient financial services. She has lead numerous revenue cycle optimization projects spanning patient access, financial assistance and up-front collections, charge capture, charge master standardization, coding and clinical documentation improvement, and various back office enhancements such as lock box and outsourcing. Valerie also has significant experience in leading compliance due diligence in support of M&A as well as defense strategies surrounding OIG, DOJ, RAC, and other audit agencies including state Medicaid programs. She has served as an expert witness in litigation.
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