ICD-10 reimbursement


Dimondale, MI
Best answers
I am hoping there is someone out there that can guide me in the right direction. I am looking for a website that I can plug in some ICD-10 diagnosis codes to find out what specific reimbursement would be ie. on a knee x-ray with a diagnosis of unspec. knee pain v.s. what payment would be for right knee pain.
I am looking for something that I can show Physician's that will get there attention and want to improve there documentation for specificity. Any suggestions would be helpful
I don't know of any such website, but the scuttlebut in the industry is that for the first year or so, the payers may accept "NOS" codes; particularly if crosswalked from the ICD-9 codes. After the honeymoon period, it's expected (by industry experts) that payer contracts will be ammended to link reimbursement to code specificity. There is information on the DRG grouper conversion from ICD-9 to ICD-10 on the CMS website, that can give you some idea from an inpatient perspective, but it's not particularly helpful specifically for physicians, unless they're hospital employed....and then the hospital is going to expect more specific documentation so that they get their $$.


So....long story short is that we suspect that payer contracts will change to reflect the need for the higher specificity. Our CMS contractor, NHIC came out in a webinar and said (althought the transcript doesn't mention this....) that they will pend claims that are coded with an "NOS" in ICD-10, and will request further information. The commercial payers are maintaining their silence at this point; I suspect they're having all they can do to make sure their systems will actually be able to process the new claims, so they're probably going to cut us some slack for the first year or so anyway, but I wouldn't take that to the bank, since it's likely that some payers will grab the opportunity to use the specificity factor to their advantage by pending those NOS claims. I suggest you contact your payer reps and see if you can get their take on how they expect this to pan out.
I can not answer the question regarding allowables, but I can tell you that payers are slating the unspecified codes for future review. What I mean is, if we are to code to the highest level of specificity, and codes are coming in for otitis media, unspecified ear, the payers will be watching for overuse of these unspecified codes. Certainly the physician knows if it was left, right, or bilateral. I know the physicians want to see the bottom line. So, you can share with him the amount you receive now vs a big fat goose egg for future use of unspecified codes. Or at least a significant delay in payment (for review of the claim) when all that was needed was laterality. Hope that blunt reply was helpful. =)
Michelle Hanson, CPC
The concern should be accurate coding so that when your documentation is audited, the response doesn't come back that you should have been more specific and they will want their money back. I highly doubt a different DX code will result in higher reimbursement, most insurances have a set amount - it's either payable or it isn't. The question is - do you deserve the payment with the way you have coded it.