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ICD-10 Expansion: A Checklist for Providers

How practices can avoid increased rejections and denials as the grace period ends.

iHealth Solutions LLC (iHealth), a technology-enabled revenue performance services and advisory company, has released the following checklist for providers as they adjust to first major changes to the ICD-10 since implementation of the new coding set in Oct. 2015.

Effective Oct. 1, 2016, physician practices and medical groups may experience increased claims rejections and payer denials following the conclusion of a one-year ICD-10 grace period established jointly by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) in 2015.

"We expect carriers will reject claims containing unspecified codes and target these encounters for retrospective audits and revenue recoupments," said Renee Stamp, CPC, COC, CPC-1, CPMA, director of reimbursement for iHealth.

Coding Each Encounter

There are some legitimate times to use an unspecified code. 

For example, a provider may know the patient has pneumonia but the specific type is unknown until additional diagnostic testing is performed. 

This could be especially problematic for family practices who know a condition exists and assigns an unspecified code prior to additional tests being performed or consultation by a specialist.  CMS states that providers should code each healthcare encounter to the level of certainty known for that encounter.

SEE ALSO: Are You Ready for the ICD-10 Expansion?

In addition to the conclusion of "relaxed rules" for ICD-10 coding on Part B claims, providers must also update their systems and staff on thousands of coding adjustments taking effect Oct. 1, 2016.

"Important changes are ahead for physician coding, and practices must be prepared," said Stamp. She advises the following steps before the Oct. 1 deadline.

A 3-Point Checklist

1. Audit: Conduct an internal audit of all claims with unspecified ICD-10 codes to identify gaps or errors in physician documentation and coding. Check use of unspecified codes when documentation backs up a more detailed code. Also check EMR documentation templates and systems for ICD-10 code specificity and FY 2017 updates.

2. Educate: Take appropriate remediation efforts based on audit findings. Provide training and education for every step in the revenue cycle: from front desk intake to claims submission. Ensure the coding on each claim aligns with the clinical documentation.

3. Monitor: Build a process whereby any staff receiving a payer denial or claims rejection due to coding communicates direct feedback to providers and practice managers. Focus on aligning specific ICD-10 codes to clinical documentation.

"It is important for practices and medical groups to review the fundamentals of compliant documentation, coding and billing as they face this new set of ICD-10 challenges," said Stamp.

Smaller practices are often understaffed and struggle to keep up with day-to-day business demands. They also lack knowledgeable coding resources to conduct internal audits and reviews.

The resources offered by iHealth were established to assist practices in these areas. To learn more about the company's Revenue Cycle Performance™ solutions, including expert coding services for physician practices and medical groups, visit:

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