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Rheumatology Practice Management December 2015 Vol 3 No 6 - ICD-10 Update
Gail Thompson

October 1 is behind us. The International Classification of Diseases, Tenth Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) is the new standard of the land. It was mandated that all healthcare providers in the United States comply with exclusive utilization of the ICD-10 coding system as of October 1, 2015.

However, even as we have struggled to add training and changing forms and systems to comply, the challenges are not yet over. Now that ICD-10 has become a reality, rheumatology practices are still going to face uncertain income, unready payers, delays in payment, and possible take-backs of paid monies following audits after the fact.

Unready Payers

We knew before October 1 that all healthcare providers must comply, but that not all payers were going to be held to the same standard. Four state Medicaid programs that have been touting their readiness for years seemingly announced a new state of unreadiness at the last minute. However, the Medi-Cal website notes that Centers for Medicare & Medicaid Services (CMS) approved a crosswalk solution for implementing ICD-10 in July 2013. The website also states that Medi-Cal has been ready to process Medicaid claims using ICD-10-CM/PCS codes since September 2014, but that it is using a crosswalk to adjudicate claims on or after October 1, 2015.

The Medicaid programs in California, Louisiana, Montana, and Maryland all received CMS’s approval to take the incoming claims submitted by practices with ICD-10 coding, convert those claims back to ICD-9 codes, and run them through their system for payment. These Medicaid programs are not making the crosswalks public, so practices will need to scrutinize payments from the affected Medicaid programs carefully until the crosswalk system is nullified when ICD-10 claims can be processed directly. No date has yet been announced as to when these programs will become ready to directly adjudicate claims.

Practices in these states will need to carefully track the payments they receive versus what they expected to receive. The affected state Medicaid programs have stated that if providers feel the payments are inaccurate, they should follow the normal appeals process for contested claims.

Delays in Payment

Practices should have a good idea of the time frame needed to receive payments from each of their major payers. Delays of even a few days outside of that time frame will need to be tracked and addressed quickly, to raise awareness of the delay and to request clarification about the length of any delays. Most practices obtained lines of credit well in advance of October 1, 2015, in anticipation of possible delays in payment, but no one really wants to tap into a line of credit to cover operational expenses.

Uncertain Income

Even if a payer is ready to adjudicate ICD-10 claims and keeps to a timely payment schedule, practices will want to review each payment as it comes in for accuracy. There are some ICD-9 codes with no corollary in the ICD-10 system, and if crosswalks and payment edits need to be adjusted, it will be important to catch that early with individual payers. The services are the same, and only the diagnosis codes are being modified, so practices’ net receipts for treatment should not change materially after October 1 from what they were before that date.

Possible Take-Backs

Documentation will be the greatest challenge for physicians. Correct ICD-10 coding may be adjudicated and paid, even with some leniency for a period of time for families of codes; however, if the documentation in the chart does not support the coding, audits could lead to possible take-backs of monies already paid. The new need for documentation is significant, and the risk for noncompliance on an audit is also significant. What does documentation need to now cover to match ICD-10 coding changes?

There are ICD-10 codes for documenting the history and possible source of the rheumatologic condition, including personal history or work or lifestyle exposures. The documentation in the chart must match the choice of ICD-10 codes, and those ICD-10 codes must be present on the claim for a full claim.

Combination codes
Some diseases, such as sickle-cell disease, are now coded as combination codes for the type of disease and a notation of any crisis, and the specific type of crisis.

New order
Under ICD-10, a patient admitted for the treatment of anemia that is related to a malignancy must be coded with the malignancy as the primary diagnosis and anemia coded secondary. Documentation must support this coding. This order is the opposite of the ICD-9 coding conventions.

Potential Impact

October 1, 2015, marked the first step of a new era for medical coding, whether good, bad, or ugly. The devil will be in the details for practices, and we are far from knowing what the ultimate impact of these changes will have on our operations, payments, and data collection.

These new codes are expected to improve patient care, clinical research, practice documentation, and quality of care. However, in an era when we have been trying to collect more data and better understand clinical efficacy, we have identified a major barrier in the matching of treatment under ICD-10 coding with previous treatment under ICD-9 coding.

Watch your backs, your revenues, your documentation, and any place where a diagnosis code is used. Continue regular communication and tracking of your payers and every claim to ensure that you are paid appropriately for the services you provide.

Stay on top of your vendors and internal processes to catch any glitches or gaps in information and tracking. We will get past this; let us hope it will not be too painful.

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Last modified: February 19, 2016
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