Troubleshoot and Fix Possible ICD-10-CM Revenue Cycle Issues

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  • July 1, 2013
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The “new” code set will bring back end workflow changes; prepare now to save money later.

By Yvonne Dailey, CPC, CPC-I, CPB
The Centers for Medicare & Medicaid Services (CMS) is holding firm on the ICD-10-CM implementation date of Oct. 1, 2014. Although we don’t know exactly what affect the code set change will have on the revenue cycle, we do know the best way to face the unknown is to prepare early. To get the ball rolling, consider ICD-10-CM implementation issues that may affect your billing system.
Assign the Right Person for the Job
Assign a lead person to address all of your claim submissions to ensure things don’t fall through the cracks. Once you find that person, begin by reviewing your current workflow for claim submissions. This will enable you to see what areas will be affected and how it should be handled.
Regardless of whether you are on a paper system (charge tickets) or an electronic health record (EHR) system, the office needs to run a frequency report for the most commonly used diagnosis codes. Create a crosswalk between the current ICD-9-CM codes and the equivalent ICD-10-CM codes. This will enable you to see whether the level of specificity has changed and how the changes will affect documentation and code selection. For example, you may need to add “laterality” as a component of a code.
Because of ICD-10-CM code specificity, carriers are saying they may not cover unspecified codes. Eliminating those codes from your system, wherever possible, is an easy solution.
Spot Shortfalls in Documentation
Offices should begin now to perform mini chart assessments for ICD-10-CM documentation to be sure providers are recording enough detail to choose codes accurately and effectively. Addressing this issue now will eliminate having to go back to query your providers after Oct. 1, 2014. Even though you may not be using “laterality,” for instance, it’s simple enough for providers to begin documenting that information now.
Providers, billers, and coders need to work closely together to make everything run smoothly and reduce the time required to go back and forth with inquiries. Without the proper documentation, coders and billers will not be able to process claims. They can help assist providers by informing them of what is necessary to get claims paid. For example, they can alert them as to the necessary information for coding and billing laboratory procedures and/or radiology. Working together will help ensure success.
Make Sure Your EHR Is Online
If you use an EHR or practice management system, you’ll need to ask your vendor how your system will be updated with the new codes. Often, updates are tied to the support contract. If you haven’t been keeping up to date on support, you may have to pay extra for these changes.
Keep in mind: Generally, when these updates are performed, your system will get all of the codes available at the time of the update. Often, if a code needs to be extended, it doesn’t happen automatically. Ask how these updates will be handled. For example, will the codes be updated already, or will your staff have to enter them manually after Oct. 1, 2014?
Review Carrier Contracts
Now is also a good time to review your carrier contracts; some contracts are tied to specific diagnosis codes. Contact your carrier and ask how those codes will crosswalk to ICD-10-CM codes, as this will greatly affect billing and reimbursement.
Get on Board 5010
In preparation for ICD-10-CM, your practice management system was supposed to be converted from version 4010 to 5010 as of Jan. 1, 2012. Version 5010 is the latest Health Insurance Portability and Accountability Act (HIPAA) electronic administrative transactions standard—which, in layman’s terms, means the way your claims are sent and received electronically by clearinghouses and carriers.
Although the implementation deadline has come and gone, there are still some systems that have not made the transition. It’s important to ask your vendor, billing agency, and clearinghouse if the system being used to process your claims is in compliance. Some clearinghouses are able to take your 4010 claims and convert them to 5010; however, when the new code system goes live, they may not be able to do this any longer.
CMS has a great side-by-side comparison to understand the difference between 4010 and 5010. One change is the need to have the correct National Provider Identifier (NPI), not only for your staff, but for your referring providers, as well. Carriers will read the NPI in combination with the tax identification or Social Security number to identify the rendering physician. This is something billing agencies must keep up to date because providers don’t include referring providers’ NPIs. Review your system and make sure you have all of your referring providers’ information in your system now.
Another thing to watch out for: Version 5010 allows for an increase in the number of diagnoses that can be submitted with a claim; however, some carriers have stated that although they are able to accept up to 25 diagnosis codes for an 837I file (UB-04) and up to 12 diagnosis codes for an 837P file (CMS-1500), for billing purposes, only four codes can be linked on a specific service line level. Check with your payers to make sure you are entering and linking procedure and diagnosis codes correctly.
When Paper Claims Are Still in the Picture
Often a carrier cannot accept claims electronically. Instead, the practice submits all of their claims electronically to the clearinghouse, and the clearinghouse drops and mails the paper claims to the carrier on behalf of the practice. If you have a similar setup, inquire whether the clearinghouse will continue this practice after the conversion and how it will be handled.
Not All Contractors Will Make the Change
Another area to review is your current workers’ compensation and auto claims contracts. These payers are not required to convert to the new coding system; the option will vary from state to state and from carrier to carrier. If you process many of these claims, ask carriers what their plans are. This will greatly affect chiropractic and physical therapy facilities, for instance, and may require you to maintain duel systems.
Learn the Reports Inside Out
Vendor, clearinghouse, and carrier electronic data interchange (EDI) departments all speak in terms of numbers for set reports. For example, 837I claims are for institutions that file claims on a UB-04; 837P claims are submitted by physicians; 835 are remittance advice forms; and 997/999 are acknowledgement reports. Familiarize yourself with all of the reports and their correspondent numbers, as you may need to work with your vendors to fix any issues (e.g., if you are appealing timely filing, the carriers may request a specific report).
If your system has made the changeover to 5010, review your EDI reports to familiarize yourself with the changes.
Monitor Payments and Denials
Assign someone to track and manage any denials. Because of uncertainties associated with ICD-10-CM, have someone stay on top of denials, appeals, improper payments, and other issues the code set change will bring. To offset payment delays and other unexpected costs that may initially occur, you may want to set up a cash reserve, too.
Many practice management systems can track whether you receive improper payments based on fee schedules. For that feature to work, the fee schedule must be entered into your system. This may seem like a lot of work, but it will greatly assist you during the transition. There are clearinghouses that offer this service, as well.
Testing, One, Two, Three
Finally, ask your vendors and carriers when they will test the new code set with your system. Allow plenty of time for testing between your system, the clearinghouse, and the carrier—or you and the carrier, if that’s the case. This transition is vendor dependant. There may be backlogs with the transition, so procrastination is not your friend.
ICD-10-CM is not just a code set change; it will bring many changes to your backend workflow. The time to prepare is now.


Yvonne Dailey, CPC, CPC-I, CPB, is owner of Dailey Billing Services Inc., founded in 2001 to provide electronic medical billing services. With more than 10 years experience in the medical billing and coding field, she teaches her clients the “key role” for correct coding and documentation and its affect on the reimbursement process. Dailey has experience as an adjunct instructor for business schools in her area and is a PMCC instructor providing seminars for physicians, staff, and new coders. She serves on the 2013-2015 NAB and has served as president for the Monmouth Ocean and Toms River local chapters and on the 2007-2009 NAB.
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