Medicare Compliance & Reimbursement

Here's how to ensure smooth sailing while payors adjust.

Just because Medicare expects providers to dive into new codes Oct. 1 without a grace period doesn't mean other payors will be ready for the change. Prepare to wear multiple hats until everyone arrives on the same page.

Many non-Medicare payors often take a few extra months to get up to speed on new CPT and ICD-9 codes. So, for example, from January until April providers will be required to use the new CPT codes with Medicare, but other payors may only accept the old codes, according to consultant Mary LeGrand with Karen Zupko & Associates in Chicago.

"Private carriers may not be using 2005 ICD-9s by October 1," leaving providers to manage two systems," worries Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, NJ. In particular, workers' compensation programs often take a year or more to get up to speed with CPT codes, according to LeGrand.

Strategy: Call all your major payors to find out what they're doing, suggests Cobuzzi. That way, you'll know what codes to use for which payor, and for how long.

"If you submit the right codes you'll get paid on appeal," says Elizabeth Woodcock, director of knowledge management for Physicians Practice Inc. in Glen Burnie, MD. Designate a "follow-up team" to track and appeal these denials. Type up a standard appeal letter for these cases, so you won't have to retype it every time.

Also, providers could be facing twice-yearly updates with no grace periods from now on. The American Medical Association is releasing temporary Category III codes in January and July, with implementation dates six months later. So providers should already be using the new Category III codes that took effect July 1, LeGrand points out.

"In prior years, the AMA said, 'You can start using [new codes] as soon as we release them,' but [providers] had additional leeway until CPT books were published in January," LeGrand says.

Heads up: The Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention may be releasing new ICD-9 codes in April, in addition to the usual October set. The extra load of ICD-9 codes could come out in January with an April effective date, or in April with a July effective date, LeGrand explains.