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ICD-10-CM: What About the Payers?
Providers and facilities are beginning to work on ICD-10 implementation, but what about health plans? Where do they fall into place?
Most health plans have been fully immersed in ICD-10 implementation for quite some time. They have also set up Steering Committees, Education Committees, and Communication Committees, just like most of us on the provider side, but their interest lies principally on internal processes and claims adjudication. They have many business areas for which we don't have to prepare, such as Medical Policies, Claims Adjudication, and Underwriting.
In the Medical Policies division, payers have many issues. All coverage determinations containing ICD-9-CM codes have to be evaluated and updated. Every ICD-9-CM code has to be mapped to all possible ICD-10-CM codes. Then, the determination has to be reviewed again to conclude which ICD-10-CM codes will be accepted as part of the policy. The same reviews must be performed on benefit policies that contain ICD-9-CM codes. This is a time-consuming and arduous process.
Once all the policies have been determined, they will need to be moved in to the claims adjudication area. Auto-adjudication software will need to be programmed to fit the new policies. The Denial and Appeals areas will most likely have an increase in workload. The people in these departments will need a solid knowledge of both their policies and ICD-10-CM to ensure that claims, denials, and appeals are properly adjudicated through the system.
The Underwriting and Actuarial departments will also be working heavily to prepare for ICD-10, converting current ICD-9-CM data to ICD-10-CM data to perform their underwriting function. If the payer offers individual plans (private policies), the underwriters will need to figure out how the approval and pricing structures may be affected by more exact data gathered from ICD-10-CM. When an individual fills out the application for a private policy, the data gathered on the applicant's personal and family health history and diagnosis information is evaluated for approval and policy premium. The granularity of ICD-10-CM will make that process more involved. The general equivalence mappings (GEMs), or some other cross mapping tools, may need to be employed to enable data to be compared and evaluated.
The above examples are just a few ways in which ICD-10-CM is touching the payers. They have a heavy up-front load to bear to enable a smooth transition to ICD-10-CM. Working together with the health plans will help us all achieve a smoother transition.
IN THE NEWS
Provider Implementation Handbooks
CMS has created four provider manuals for varying practice sizes to facilitate ICD-10 implementation. Each manual contains resources to help you plan every step of the implementation process and execute each step well.
PREOPERATIVE DIAGNOSIS: Mixed incontinence and pelvic relaxation
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Monarc and cystoscopy.
ESTIMATED BLOOD LOSS: Less than 25 mL.
DESCRIPTION OF PROCEDURE: After informed consent had been obtained, the patient was brought to the OR, placed supine and general anesthetic was induced without problems. She was carefully padded and then shaved, prepped, and draped in sterile fashion after she was moved to the dorsal lithotomy position. ALPS were placed prior to induction of therapy and she received IV antibiotics. A Foley catheter was placed in her bladder and the bladder was completely drained. 0.2 5% Marcaine with epinephrine was used for local anesthetic. Two small stab incisions were made along the inner thigh just at the medial border of the obturator foramen and below the abductor tendon. This was at the level of the clitoris bilaterally. A midline incision was made centered over the urethra from the bladder neck with the scalpel and vaginal flaps were dissected. Care was taken to make sure the flaps were of sufficient thickness, but that we did not dissect too close to the urethra. The Monarc trocar was then carefully passed through the inner thigh incisions and then finger guided out the vaginal incision. Care was taken to make sure that the trocars did not button hole the vaginal flaps and that they were in good position. The Monarc with its protective sleeve was then snapped into position and brought out laterally. Copious amounts of antibiotic irrigation were used throughout. The Foley catheter was removed and a 21 French rigid cystoscope placed into the bladder. The bladder was carefully examined using both the 30 and 70 degree lens, as was the urethra. There was no evidence of any trauma to the urethra or the bladder and the sling appeared to be in good position. The protective sleeves were then removed. Care was taken to make sure that the Monarc provided good support, but that there was no undue tension. The excess sling was trimmed. The vaginal incision was closed with 2-0 Vicryl and a few interrupted sutures and the inner thigh incisions closed with chromic. Dr. X then proceeded with the rest of the procedure, which will be dictated separately. All needle and sponge counts were correct, and there were no apparent complications during the first portion of the procedure.
N39.46 Incontinence, urine, mixed
N81.89 Relaxation pelvic floor
Rationale: In ICD-10-CM subcategory N39.4- has a note to code also any associated overactive bladder. There is no note of overactive bladder so this is not coded for this case.
ICD-10 Implementation Strategies
In this section, we share strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.
Talking with Payers
Good communication with payers is imperative for conversion to ICD-10-CM. Many payers have a Provider Outreach department or a department that includes provider communication. Check with your biggest payers and get in touch with someone from that department. Discuss where they are with ICD-10-CM implementation, including acceptance of 5010 for January 2012. Ask when you might begin to see new coverage determinations and policies so you can assess them and have time for negotiations if necessary. Early, often, and open communication will ensure fewer obstacles on the road to ICD-10-CM. This will also help when ICD-10-CM is live and issues "pop up" unexpectedly. If you already have good relationships built, you may be able to get your issues addressed and answered quicker.
Superbills are still used in many offices today to track patient visits and input information for coding and billing. A superbill conversion was performed to demonstrate the complexities of the new system and assess the impact of ICD-10-CM on superbills. The results will assist your office in its evaluation of the use of superbills for ICD-10-CM diagnosis coding.