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Deb Grider

As we all know, football season has started again, and it is time to get back in the game. But football is not the only thing we should be thinking about right now. It is time to jump-start your ICD-10 game plan as well.

I am certain everyone in the healthcare industry has heard that on Aug. 24, 2012, the U.S. Department of Health and Human Services (HHS) published the final rule pushing the ICD-10 implementation date back one year to Oct. 1, 2014. Since many organizations have been struggling to get ready for ICD-10 – or have not even started – this breathing room will allow all HIPAA-covered entities the extra time needed to complete all their relevant projects.

But that doesn’t mean we can bury our heads in the sand and ignore ICD-10 until 2014. There is so much to do, and little time to accomplish the tasks at hand, so you must get into this game this very minute. It seems like every article on ICD-10 I encounter focuses on documentation and the challenges we face in this area. Yes, it is true that improving documentation and working with and educating physicians in this area is a very important step. But that is not the only step.

Since the proposed ICD-10 rule first was published in 2008, and even before that, ICD-10 implementation efforts were focused squarely on information systems, health information and coding – yet now the focus seems to be only on documentation. I agree that documentation is very important, but there are other issues that will demand significant attention and should be considered as well.

Payer Contracts

What about the other key challenges we face? Let’s take a brief look at one important issue: your payer contracts. Have you considered looking into the necessary language changes to your contracts under ICD-10?

As the ICD-10 go-live date quickly approaches, providers – including hospitals, physicians, long-term care and all others – need to scrutinize their managed care and payer agreements, and ultimately reimbursement as well. Without proper reimbursement, any organization will cease to function. We can forget about it and simply wait to lose, but taking a proactive approach will ensure a resounding win.

Considering all variables from the perspective of the claims submission process will bring clarity to any potential issues and should present opportunities to preserve revenue stream integrity. Will all payers ensure a financially neutral position? Some payers now are writing ICD-10-specific language into their managed care and commercial contracts/agreements.

For example, a review of one payer contract indicates that financial impacts need to be evaluated within a reasonable time from ICD-10 implementation. One payer contract I reviewed had specific language stating that “rates will be adjusted for any applicable contract year inflator or quality incentive, if applicable, and then neutralized for any positive or negative impact from implementation of ICD-10.” The contract goes on to indicate that “a formal review of the impact of ICD-10 coding changes may be initiated if any such coding changes have a change equal to or greater than 1 percent of the total amount paid by the plan to facility for inpatient or outpatient services for all commercial lines of business.”

The goal is to have claims paid appropriately and coded accurately, per ICD-10 coding convention and guidelines, and accepted by the payer for adjudication and subsequent reimbursement based on contractual payment provisions. Ideally this will be done with no rejections, pended claims or denials causing providers to correct and re-bill claims, which ultimately causes delays in payment. Again, payers are integrating very specific contract language addressing ICD-10 and its potential impact on reimbursement differentials.

Most payers will be very specific in their audits and review processes to “neutralize” reimbursement should new coding guidelines cause reimbursement to vary outside of the 1 percent threshold. All healthcare providers should, as part of the implementation planning, develop and implement an audit process to monitor claims after ICD-10 goes live in order to test parameters, monitor documentation and demonstrate due diligence in commercial and managed care payment validation. Will ICD-10 have an impact on your reimbursement?

Keep in mind when you are planning your ICD-10 implementation strategy that a contract language review for each contract you sign is imperative to ensure accurate and fair payment for services as ICD-10 implementation draws closer. We all want to score a few touchdowns and win the game, and the path to success involves paying attention to your ICD-10 game plan.

About the Author

Ms. Grider, an AHIMA-approved ICD-10 trainer and an American Medical Association coding author, is a senior manager with her firm, possessing more than 30 years of experience in coding, reimbursement, practice management, billing compliance, accounts receivable, revenue cycle management and compliance across many specialties. Her specific areas of expertise include medical documentation reviews, accounts receivable analysis and coding and billing education.

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