Patty Buttner, RHIA

In today's world of ever changing reimbursement models, as well as the nearing implementation of ICD-10, physician practices need to approach the revenue cycle from both a proactive and reactive perspective. Practices need to evaluate their current revenue cycle to determine and address negative affects when ICD-10 is implemented.

The revenue cycle begins with the first contact from the patient. Education and training of the front-desk staff is paramount. Accurate demographic and coverage information needs to be obtained during the initial contact with the patient, either via phone or in person and then verified at each patient visit. Copays should be collected during the check-in process.

A proactive step that could save the patient and staff time during patient check in is to verify and communicate to the patient or responsible party the copay responsibilities prior to the office visit.

With the implementation of ICD-10 there may be additional steps required to ensure the proper codes are assigned for the visit and claims are not denied in error. Has your staff been trained in ICD-10? Coders and billers are not the only staff that will require training. The front-end staff of a practice needs an understanding of the code set as does pre-certifications, claims reconciliation, and appeals staff.

It is essential to review and evaluate claims denials. Compile a list of the denials, ordering them by largest impact on the practice. Create a schedule and plan to work from the most significant to least significant.

Conduct an analysis of the denials. Are there denials due to lack of medical necessity? Are claims denied for lack of support for the level of evaluation and management code assignment? Review the ICD-10 codes assigned for the visit to ensure accuracy. A review of the provider's documentation may reveal that there is an opportunity to work with the provider on improving his documentation to support all billing and to capture all pertinent diagnoses. Is there a need for a clinical documentation improvement program? Does the potential return on investment support the need for the expertise of a clinical documentation improvement professional?

If there is a significant amount of denials due to lack of pre-authorization or pre-certification review the current process, inquire: Were the correct ICD-10 codes assigned during the authorization process? A lack of understanding or education in both ICD-10 codes and the pre-authorization process may lead to an increase in denials. Additional education may be required.

On the back end, reconciliation of claims should be conducted. Is the practice being reimbursed per the language of the contract? Are the correct copays being collected by the front-office staff? Review the current payer contracts. Contact the payers to discuss the implementation of ICD-10 and any potential impact due to changes in code sets. It is best to hold these discussions now instead of taking a "wait and see" stance.

The practice should have an appeals staff and processes in place for working denials and appealing when appropriate. All payers have an appeal process that providers must follow. Many of the payers provide the information on their websites. The staff member in charge of appeals should be aware of the various appeals processes of the payers. CMS has several levels of appeals. If the claim requires correction of minor errors and omissions, CMS has a streamlined process that can be used without having to go through the appeals process. A link is provided in the resources section of the article MLN Matters Number SE0420 which provides information on the "Correction of Minor Errors and Omissions without Appeals." (

CMS, under HHS, created a booklet detailing the five-layer appeals process that begins with the Medicare Administrative Contractor (MAC) at level one and ending with a judicial review in the U.S. District Court at level five. (

Due to a potential increase in denials there may be an increase in claims resubmission. Practices should begin planning now to increase staff or evaluate the need for temporary employees to assist with the management of denials, appeals, and resubmission of claims.

Another area for consideration is payment delays from payers. There may be delays from payers for various reasons related to the implementation of ICD-10.

CMS has provided information related to potential reimbursement issues from payers. According to the ICD-10 Implementation Guide located on the CMS ICD-10 website, there may be payment delays due to:

• Payer systems not updated from ICD-9 to ICD-10;

• Errors in the translation of ICD-9 to ICD-10;

• Delay in updating pre-certifications obtained under ICD-9 to ICD-10;

• Manual processes related to performing adjustments; and

• Possible increase in duplicate claims which will affect timely reimbursement.

Frequent communication and meetings between the staff working with front end or the back end of the revenue cycle will provide opportunities to discuss current denials. There will also be process improvement opportunity conversations that may lead to reducing those denials. It may also reveal where more robust education should be provided to the staff.

Proactively addressing issues that lead to denials will decrease the reactive process on the back end leading to a cleaner revenue management cycle and reimbursement process.

Physician practices need to create a plan to address the issues that may interfere with prompt reimbursement of claims. A complete review of processes in place today will identify opportunities to improve the revenue cycle within the practice which may decrease delays on the front and back end.

, CDIP, CHDA, CCS, is an American Health Information Management Association-approved ICD-10-CM/PCS trainer and director of Health Information Management Practice Excellence in coding for AHIMA.  She can be contacted at 

This article originally appeared in the September 2015 issue of 

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The upcoming coding change requires reimbursement monitoring by practices and perhaps a review of claims appeal processes as well.

ICD-10's Potential Effects on Your Revenue Cycle

Now that your practice has reviewed its budget and determined training needs for the ICD-10 code transition, it is time to assess readiness and the systems that utilize diagnosis codes. There may be areas in the practice outside of claims that regularly use diagnosis codes. It is important to conduct a systems inventory to ensure all hardware and software is evaluated for ICD-10 readiness.

It is important to identify all the employees that regularly use diagnosis codes and the resource(s) they use to assign those codes. Here are some questions the practice should ask:
• Who in the practice assigns diagnosis codes and how are they assigned?

• Are they assigned in the EHR system or are code books used?

• Are advanced beneficiary notices (ABNs) issued to patients and how are they produced?

• What resources are used for the precertification and authorization process?

Consider the referral process and what resources are used to complete referrals. Assess the practice for any other internal departments that may utilize diagnosis information. It is important to survey the entire practice and staff as part of your readiness plan and assessment.

If code books are used for all or any of these functions, order them early in 2015. Identify diagnoses most frequently assigned. Once identified in ICD-9, recode them with ICD-10 codes. A frequently used diagnosis codes list can be a very useful tool. Provide time for the office staff to practice assigning ICD-10-CM codes.

Keep in mind that physician billing methods are not changing. Physicians will continue to bill and receive reimbursement based on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding Systems (HCPCS) codes. The diagnosis codes help to support the procedural codes assigned and complete the full patient story.

What systems use diagnosis codes? What software or hardware needs modifications or replacement to accommodate ICD-10 codes? It is important to create a checklist of all the systems utilized in the practice and if diagnosis codes are associated with that system. Assess the entire practice for any system that utilizes coded data and include those systems in the systems inventory.

Conversations with vendors should have already taken place. CMS has a wealth of resources available for physician practices. For a complete list of vendor readiness questions and tools, utilize their "Road to 10" quick references (available here: bit.ly/ICD10-references). The AMA also has resources available for members and nonmembers (bit.ly/AMA-ICD10-references). The American Health Information Management Association (AHIMA) provides many resources for members and nonmembers as well (bit.ly/ahima-ICD10).

• When will the system be ready for testing and implementation?

• What is the availability of customer support?

• Will the system accommodate both ICD-9 and ICD-10 codes?

Trading partners (your clearinghouse and/or billing system), the practice management system, and the EHR are the major systems that need to be tested. Consider how superbills or encounter forms are generated in your practice (i.e. paper vs. electronic). Check the practice's systems inventory to ensure that all hardware and software that utilize coded data are tested.

If a billing service or clearinghouse is used to submit claims, a discussion surrounding changes the practice may need to make in order to send claims data is needed.

The early identification and resolution of issues discovered during testing will minimize the impact at implementation.

Talk to your vendor about testing and its availability to assist in the process. Internal testing should already be underway. Test the system's ability to:

• Produce an order or requisition with ICD-10 codes;

This should test the ability of the practice to send and receive transactions with ICD-10 codes. Many trading partners have been conducting both internal and external testing in order to be prepared for the ICD-10 implementation. Contact trading partners to determine what testing has taken place, and the results. External testing provides information on the ability to:

• Send test data to an external source;

• Receive coded data from an external source; and

• Identify issues that obstruct the ability to send and/or receive test data.

CMS has identified several weeks in 2015 for acknowledgement testing. This testing determines if your claim is successfully transmitted to CMS. This is the first step in the claims submission process. The testing does not test the entire claim process. During the identified weeks, the data is analyzed to provide information on the claims submission process; such as the percentage of claims that were successfully accepted and reasons why claims were rejected. Providers do not need to register for acknowledgment testing. CMS will make the data available once it has been analyzed.      

CMS will be conducting end-to-end testing, which tests the entire claims process from submission to remittance.

Per CMS, the goal of this testing is to demonstrate successful submission of claims with the production of accurate remittance advices.

End-to-end testing, at the time of publication, was scheduled for Jan. 26 through Jan. 30, 2015. Providers participating in this round were selected and notified in October 2014. Fifty registered volunteer providers were selected by each Medicare Administrative Contractor (MAC). There will be two additional testing weeks, in April 2015 and July 2015. To participate in the April testing, registration needed to take place in December of 2014. For information on registering for the July testing, visit the MAC website here: bit.ly/MAC-jurisdictions.

As with all new implementations, it is important to have a contingency plan. A practice needs to be prepared for any problem that may arise. A contingency plan will help reduce the impact of any unforeseen event. Examples of items to include in the plan:

• Vendor(s) readiness/lack of readiness;

AHIMA ICD-10-CM/PCS Implementation Toolkit

AHIMA ICD-10-CM/PCS Transition: Planning and Preparation Checklist

 is a director of Health Information Management Practice Excellence at AHIMA. She can be reached at patricia.buttner@ahima.org.

This article appeared in the March 2015 issue of 

An important part of ICD-10 readiness is ensuring all hardware and software is evaluated via a systems inventory.

Author | Patty Buttner, RHIA

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ICD-10's Potential Effects on Your Revenue Cycle

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