Pain Management Coding Alert

Published on Wed Feb 08, 2017 PDF

Getting denials based on Dx specificity? We've got the solution.

Practices that haven't already done so should check the claims dated after October 1, 2016, for denials based on incomplete or incorrect diagnosis codes.

Why? That's the day Medicare's grace period for ICD-10 codes ended, meaning that it expected you to submit more exact diagnosis codes starting in October. If your denials spiked in October, you might need to take action to sharpen your practice's ICD-10 skill.

Here's more on the end to the grace period, and what you can do if you're singing the ICD-10 blues due to claim denials.

Audit Returned Claims

Although CMS gave you that "grace" for one year following the implementation of ICD-10, most other payers did not. That's why you've probably been coding correctly anyway. "Many major insurers did notoffer coding flexibility, so many providers are already using specific codes," said Centers for Medicare and Medicaid Services (CMS) spokesperson Jibril O. Boykin.

But the end of the grace period may mean you have an increase in denials if you haven't been applying the level of specificity ICD-10 truly requires.

Do this:  Run a claims audit including all your major payers on claims filed since Oct. 1, 2016, and see if you have a significant change in denial rates based on inappropriate diagnosis code for the procedure. Then use that information to inform physicians where they need to tighten their documentation to help coders report conditions to the highest specificity available in ICD-10.

Switch 'Update' Mechanism to 'On'

If you've gotten lazy about updating your system's diagnosis code set because CMS froze new updates to ease the transition from ICD-9 to ICD-10, you need to break that habit now.

During that freeze, lots of updates accumulated and came gushing out on Oct. 1. Some of those changes turn a four-digit code into a more specific five-digit codes. Missing those changes means certain denial for filing a "truncated" code.

Do this: Just as you used to update your ICD-9 code sets at least once a year to make sure you were using the most current options, you'll need to restart that process for ICD-10. Now that ICD-10-CM 2017 broke the hold, you can expect annual updates each year moving forward.