Billing for ICD-10: Be prepared

As I visit with physicians around the country as part of my business, I am amazed at how many express little concern about the transition to ICD-10 diagnosis codes next year. I have categorized their comments into four categories of myths that appear to be widely believed in the renal industry.

Myth #1: ICD-10 will not affect nephrology much

Nephrology and outpatient dialysis are unquestionably less affected than other areas within health care. However, just because nephrology is less affected does not mean that it is not significantly impacted. I picked up a booklet from a renal organization earlier this year and they had identified the most commonly used diagnosis codes for nephrology. The booklet contains more than 150 diagnoses that should be used along with about two dozen codes that should be excluded dependent upon your choice of primary diagnosis.

While a number around 150 sounds manageable, how do these 150 or so diagnoses apply to commonly billed procedures? To get some idea I reviewed the diagnosis codes used by a small two-physician nephrology practice during 2013. The practice billed out procedures that required 441 distinct diagnoses under ICD-9. While some of the ICD-9 diagnoses translate to ICD-10 on a one-to-one basis, I identified approximately 1,300 codes that could have been used depending on the specific circumstances of each patient. In a few cases, physicians could also have to choose from 500 additional ICD-10 diagnosis codes.

Myth #2: My EHR will handle the coding for me

While Electronic Health Records (EHRs) will be an important tool to help you navigate ICD-10, tools can provide varying results depending on the quality of the tool and the skill of the person using it. As an example, a physician billing under ICD-9 coding can state he or she saw a patient for hypoparathyroidism and there is a single code that captures that diagnosis. Under ICD-10, there are four possible codes to choose from. In order to accurately determine which code to use, the physician must provide additional detail for the person doing the coding. If the physician is the one coding by choosing from a list of diagnoses within an EHR, he or she must be familiar with the type of logic used by the EHR to determine which code is the most correct. EHRs that list all related codes or that provide decision-making tools to guide the physician to the level of specificity required would likely best serve a physician or coder.

Physicians and coders should be aware that some ICD-9 to ICD-10 translation tools selects a “best” or “most likely” code that may or may not be the most correct code for the condition for which the patient is being seen. Thus, the more familiar a coder or physician is with ICD-10, the more accurate the coding and the less likely they will experience claim rejections or recoupments of previously made payments following a claims review.

Myth #3: There will not be a major delay in reimbursement

The original plan for the implementation of ICD-10 by CMS was to update their claims processing software, run a few internal tests, and then start processing claims without doing any end-to-end testing. Fortunately, many in the health care industry demanded end-to-end testing and CMS agreed to do this on a limited basis. Some testing was done earlier this year and another round of testing was scheduled for July.

When ICD-10 was delayed a year, many of us rejoiced thinking this would give CMS more time to perform end-to-end testing and ensure that their claim system would process claims correctly by October 1, 2015. However, instead of going ahead with the testing scheduled for July, CMS canceled it and announced there will be additional testing in 2015. The delay in testing has renewed concerns that the CMS claims system will be fully ready next October.

Prior to the delay, health care consultants and executives recommended that providers have at least three months of funds set aside or a line of credit available in the event that CMS and other payers experience significant delays in processing and paying claims correctly. Barring extensive testing by CMS and other payers next year, setting aside funds or securing an extended line of credit is still wise. Currently, CMS updates its claims processing system every quarter. Nearly every quarter there are unforeseen issues with claim processing caused by the changes to the system. For example, earlier this year CMS discovered that the January update to its claims system caused dialysis claims to process incorrectly. Many facilities experienced at least a 30- day delay in receiving their reimbursement.

If a relatively small change can cause that type of delay, what kinds of delays might be caused by the massive system-wide change to ICD-10? Medicaid and commercial payers will also vary in their ability to correctly process ICD-10 claims. Smaller payers and those with limited resources such as is the case with some state Medicaid programs may experience significant delays in their ability to correctly process and pay claims.

Myth #4: I can continue to do things as I have always done them when it comes to billing payers

Physicians still using paper superbills should seriously consider finding an EHR and implementing it as soon as possible. I looked at three different paper superbills currently in use by nephrologists. Under ICD-9, they were one page. I took one of the forms and converted the diagnosis codes from ICD-9 to ICD-10. The one page form is now three pages. How convenient will that be to work with, not only for you, but also for your coders and/or billers?

Buying and implementing your first EHR or changing to a new EHR well in advance of the implementation of ICD-10 will save you countless hours of frustration and help reduce billing and coding errors. There is a learning curve with every EHR and neither you nor your staff should be trying to learn both a new EHR and ICD-10 coding at the same time.

Physicians should also ensure that their billers and coders receive ample training in ICD-10 prior to October 1, 2015. Spending additional money to educate billing and coding staff will cost much less in the long run than having claims rejected, payments delayed, and money recouped due to incorrect coding. Physicians who are not confident in their billing and/or coding personnel should consider outsourcing their billing to an organization that is experienced in renal-specific billing. Outsourcing to a company that is not already familiar with renal billing will require your new billing company to learn nephrology and ICD-10 at the same time, something you want to avoid.

What should you do?

Strongly consider purchasing your first EHR or changing your current EHR to provide you with assistance in capturing the level of detail needed for coding under ICD-10. Implement the EHR well in advance of October 1, 2015.

Set aside at least three months worth of funds or secure an additional line of credit that will allow you to meet your expenses in the event of significant delays in claim processing and reimbursement.

Begin now to train everyone involved in coding—physicians, nurses, coders, and billers—in ICD-10 and continue to provide training throughout the transition.

-by Rick Collins