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Physician practices have had nearly a year to acclimate themselves to the ICD-10 coding that took effect in October 2015. Thanks to a grace period known as ICD-10 “relaxed rules,” which were established jointly by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA), the use of ICD-10 codes that did not meet the highest level of specificity requirements was allowed to continue without the risk of punitive action.

This granted a reprieve for practices, allowing them more time to adapt to the vast new code set. But that all ends on Oct. 1, 2016. 

While no one is exactly sure how payers will address ICD-10 coding issues after the grace period ends, it would be helpful to understand what such issues could arise, and how providers and coding professionals can address them.

One of the main issues that has surfaced in the transition from ICD-9 to ICD-10 was the allowed abuse of unspecified codes in the ICD-9 code set. In the move to ICD-10, these codes have become much more detailed. Moving beyond Oct. 1, 2016, carriers will be expecting the highest level of specificity in coding. 

It’s important to note that in some cases, unspecified codes are acceptable. For example, with congestive heart failure, for the first few times a patient is suspected of having that diagnosis, use of the unspecified code is acceptable until the appropriate testing is conducted to determine whether the condition is affecting the left or right ventricle. The physician can get into the specificity of these codes once diagnostic tests are interpreted.

In other cases, however, such as with asthma, unspecified codes have been overused. With ICD-10, upon examination of the patient, a physician should be able to determine if the condition is acute, chronic, or exacerbated, and then drill further down to the highest level of specificity. 

Breaking ICD-9 Coding Habits

Probably the biggest challenge physicians face with the expiration of the relaxed rules is, quite simply, overcoming their ICD-9 coding habits. The extreme abuse of ICD-9 unspecified codes resulted in physicians failing to achieve the highest level of specificity – and frankly, carriers not really caring if they did or not. With ICD-10, carriers now will be able to request much more specific information regarding the condition or conditions for which patients are being treated.

While the use of unspecified codes can be attributed in part to habit, in other cases, it’s much easier to access them when using some of the available search tools created to identify diagnosis codes. In fact, with some search tools, the unspecified code is the first code to appear.

Over-reliance on GEM 

This brings us to another issue – general equivalency mapping (GEM) tools. GEM mapping refers to the tools used to start providers down the path of finding the right ICD-10 codes. The problem is, there is no one-to-one mapping from many ICD-9 codes to equivalent ICD-10 codes. And in comparing ICD-9 to ICD-10 codes, just one ICD-9 code now can explode into as many as 100 different ICD-10 codes. With basic tools like GEM, mapping an unspecified ICD-9 code could point to an unspecified ICD-10 code, leading the user down the wrong path. 

Also, a lot of physicians code without reviewing the description of each code. But GEM mapping tools don’t drill down to the level of specificity now required with ICD-10. This presents a huge challenge in the industry for those providers and coding professionals who traditionally have relied on such tools.

What’s Next?

There is a general fear among practices of not knowing what punitive measures payers are going to impose once they no longer need to comply with the relaxed rules. Are they going to start denying claims and returning them to providers for additional information? Or are they going to start conducting chart audits, through which insurance companies request a review of a physician’s chart notes on a patient in question? My guess is that they will go the chart audit route.

Providers should not feel that they are at the mercy of insurance carriers, though. Looking ahead, there are several things practices can do now to ensure adherence to ICD-10 coding mandates: 

  • Keep sufficient and accurate chart notes and code to the highest level of specificity – be as specific as possible when describing a patient’s condition and in your coding practices. For example, did the physician document that the condition was on the left or right side of the body? Did the physician document whether the condition was exacerbated? Did the physician use the proper family code? Remember that chart audits will delay reimbursement. What lies ahead will be a very long process of assessment, because the carrier now will have to review notes, and a human, rather than a computer, will need to make the appropriate assessment, slowing the process considerably.
  • Use a mapping tool that enables you to attain the highest level of specificity – such tools are available for private practice physicians, and they can enable them to view coding from a practice management and electronic health record (EHR) perspective. These tools differentiate end users who are practice managers and those who work in EHR, as they represent two completely different worlds – and people. For example, doctors and nurses have different personalities and enter data differently. These tools, while similar, allow for the mapping of appropriate data based on the thought processes of the person entering it. This helps them understand coding in a logical way that is attuned to their individual thinking perspective, down to the deepest code. A good tool will guide to the highest level of coding specificity in a manner similar to how clinical staff would perform an assessment of a patient in a face-to-face interaction. Alternatively, from a coder’s standpoint, the driving workflow starts with the lower code and works its way into the highest code. This will also allow for filtering options, such as left or right, which cut the large code sets into smaller, digestible choices.

Mapping tool technology was developed as an alternative to GEM, created with the understanding that ICD-9 codes have been deeply engrained in people’s minds for years. For example, if an unspecified ICD-9 code is punched in by the coder, several indicators appear on-screen. One, a dollar sign indicates that the code is a payable code. Another informs the coder that better coding choices exist. Depending on the end-user type, the tool then quickly arrives at the right level of coding specificity. Such mapping tools also “understand” which codes can be billed as unspecified and which codes, as a general rule of thumb, can be taken to the next level of specificity. 

  • Practices should also analyze the top 50 codes they are currently submitting and identify any associated unspecified codes to determine if they are appropriate to send to the carrier, based on what information was available at the time of patient assessment. They then should evaluate their charting for proper documentation to determine whether they could have reached a higher level of specificity, as well as if the diagnosis code used was in the appropriate code class. If that level of specificity is not being reached, get into the nitty-gritty of coding and ask yourself why. Is it the tool being used? Does additional training need to be given to the physician? The coder? The office manager? Was the highest level of specificity achieved on examination of the patient?
  • Start monitoring a baseline of denials and payments from carriers beginning in October and running through December. If that baseline increases, learn how practice management can be utilized to understand the details of the increase. Establish a benchmark to monitor if something starts changing in October. Keep in mind that denial codes aren’t going to provide the answer as to whether a denial was an ICD-10-related denial. But if you track an increase in your denials from October through December, it’s safe to assume that they are probably related to incorrect coding.

While ICD-10 represents a significant paradigm shift for providers and coders, it also can help establish an improved level of care for patients while ensuring that providers are properly reimbursed for their services. 

All it takes is a new mindset and the right tools.


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