During the first year following ICD-10 implementation in October 2015, physician practices have had nearly a year to adapt themselves to ICD-10 coding. This grace period, also known as ICD-10 “relaxed rules”, notes that Medicare review contractors could not deny physicians' claims if the physician did not code to the highest level of specificity. This flexibility gave physician practices more time to transition to the new code set.
The Centers for Medicare & Medicaid (CMS) recently updated its guidelines on ICD-10 claims auditing. The update notes that ICD-10 flexibilities will expire Oct. 1, 2016. Providers will have to code in as much specificity as possible. CMS also recommends providers review its 2016 ICD-10 coding guidelines.
As there are some concerns about how ICD-10 coding issues will be addressed after Oct. 1, 2016, a deeper look at the current situation might provide a better understanding.
What the end of the ICD-10 grace period means for physician practices
According to CMS, the ICD-10 grace period “will not extend ICD-10 flexibilities beyond Oct. 1, 2016. There will be no additional flexibility guidance”. Providers should already be coding to the highest level of specificity. So if practices hoped for an extension of the grace period, they’d better have a closer look at the required coding guidelines and start coding in as much specificity as possible to avoid claims rejections. Anyway, many providers are already using specific codes.
How to get ready for the end of the ICD-10 flexibilities
As of Oct. 1, providers will be required to code and reflect clinical documentation in as much specificity as possible. Unspecified ICD-10 codes should be avoided, especially when a detailed code is available. Coding on each claim should coordinate with the clinical documentation.
Organizations should conduct both internal and external coding audits. By identifying the claims submitted with unspecified ICD-10 codes and then conducting a documentation audit on those records will allow providers to focus on where a more specific code could have been submitted. Education efforts can then be tailored to the specific areas identified.
Probably the biggest challenge for physician practices has been changing their ICD-9 coding habits to new ICD-10 habits. There will be much more specific information requested regarding patient treatment. The best strategy for physicians is to keep accurate chart notes and be as specific as possible when describing a patient’s condition.
There is a list of the 2016 ICD-10-CM valid codes and code titles on CMS’s website: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html
For some medical encounters, unspecified codes are acceptable, or even necessary and will be allowed. Information about unspecified codes can be found on the CMS website (https://www.cms.gov/Medicare/Medicare.html).
Audits that begin after Oct. 1, 2016
As of Oct. 1, 2016, all CMS review contractors are able to use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to Oct. 1, 2015. Providers will be notified of coding issues identified during review and of steps needed to correct those issues to the same extent that they did prior to Oct. 1, 2015.
For healthcare, the implementation of ICD-10 has been a huge step forward to an improved level of patient care and proper reimbursement. The shift to more specificity can be painless with the right tools.
We at Primeau Consulting Group can assist your organization with the
new code set and documentation requirements to reduce your risk of denials. Contact us today to hear about out documentation and coding audits.