February 11, 2014
TOPIC: ICD-10, Revenue Maximization
Many recent healthcare industry surveys (e.g., WEDI, MGMA, AHA, AMA, KPMG LLC) suggest that the industry is still struggling towards ICD-10 compliance on October 1, 2014. However, Freed Associates is finding that our clients may be further ahead than the industry surveys suggest or present.
With fewer than nine months to go until mandatory ICD-10 compliance, Freed Associates created a simple punch list to help our clients focus on the most impactful and critical areas that contribute to success:
As a provider:
- Ensure clinical and billing systems can accommodate and support the ICD-10 code set. Providers that are not ready for ICD-10 on Ocotber 1, 2014 will quickly find out through rejected claims that ICD-10 is not “optional.” We have not seen any situations where payers intend to relax ICD-10 compliance for claims submission.
- The key to success is understanding how to submit claims according to the gold-standard of ICD-10 requirements: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf.
- Expect clinician pushback on ICD-10 until the clinicians realize that this will directly impact their revenue. Furthermore, clinicians must supply appropriate clinical documentation to allow for Coders to discern the appropriate ICD-10 code from the medical records; this requires communication, training, and change management.
- Establish a Coder training and retention program. If you do not take care of your Coder, someone else will! The industry expects a shortfall of Coding resources due to the 20-40% anticipated drop in Coder productivity.
- Start contacting your top five payers to see if you can submit a small set of test claims containing ICD-10 codes. As a provider, it is critical that payers have remediated their claims and pricing systems to continue to pay as per the provider-payer contract terms.
- Set aside sufficient financial accounts receivable reserves now instead of waiting until your Patient Financial Services department publishes their October 2014 cash posting results.
As a payer:
- Ensure all electronic data interchange (EDI), claims, benefits, and pricing systems can accommodate and support the ICD-10 codes. As with any major claims system overhaul, the key to success is to test, test, and test again.
- Identify key operational areas that may be subject to increased volumes and mitigate risks as appropriate for: Call Centers, Provider Relations/Contracting, and EDI departments.
- Start contacting your top five providers to see if they can submit a small set of test claims containing ICD-10 codes. As a payer, it is critical that any reimbursement disputes or claims acceptance issues be identified prior to full-blown production when claims backlogs may arise.
- Prepare for the risk of CMS announcing an ICD-10 grace period by ensuring that EDI and claims systems are capable of processing claims with either ICD-9 or ICD-10 code sets regardless of date of service.