Prepare to Fight ICD-10-CM Denials

ICD-10-CM will be the mandatory code set for reporting starting on October 1, 2015, unless another unforeseen issue arises in the federal government that leads to its delay.   The complexity of ICD-10-CM as compared to ICD-9-CM have gone up markedly.  This will increase the likelihood of inaccurate coding at the healthcare provider institution level, coding errors by payor representatives, and the potential for different payors creating different requirements regarding the use of ICD-10-CM.

The increased amount of time it will take to select the right ICD-10-CM code(s) is expected to have a significant impact on coder productivity, which will likely result in delays in claims submission and revenue recognition by healthcare facilities.  If this is compounded by a significant increase in denials, it could prove to be a significant financial burden on hospitals, clinics and other medical facilities.

In order to combat this healthcare organizations are encouraged to take a very proactive approach to reimbursement.   The following steps are recommended:

  1. Identify the ICD-9-CM codes that are associated with greatest amount of total revenue.  These can be referred to as high value ICD-9-CM codes
  2. Identify the ICD-10-CM codes that correspond to these ICD-9-CM codes.  These now become the high value ICD-10-CM codes.  The mapping from ICD-9-CM to ICD-10-CM is often not entirely straightforward, so this may require a significant investment of time.
  3. Develop policies around ICD-10-CM code selection and submission that meet the requirements of each payor (they may be different)
  4. Update all systems that will be impacted by ICD-10-CM at the earliest possible time (e.g., practice management software, electronic health records, etc.) to ICD-10-CM.  This may require updates to templates and other content used by clinicians at the point of care.
  5. Provide training to clinical and billing staff, but focus on codes that are relevant for the practice setting.
  6. Encourage clinicians and billing representatives to start submitting ICD-10-CM codes or perform dual coding prior to October 1, 2015, as allowed by payors.
  7. Identify when high value ICD-10-CM are denied and devote significant resources to understanding why and how this situation can be remedied.  Contact the payor representative (physician to physician communication may be needed in some instances between the provider and the payor: be persistent).
  8. Incorporate the feedback from working denials into your practice’s clinical workflow, including the EHR and practice management systems as appropriate.

The American Health Information Management Association has published information on how to approach ICD-10-CM denials. The article is posted here.

The information in this article unless otherwise attributed represents the opinions of Michael Stearns, MD, CPC.  Dr. Stearns provides informatics and compliance consulting services.  He can be reached at the following email address:

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