Rachel V. Rose, JD, MBA, advises clients on compliance and transactions in healthcare, cybersecurity, corporate and securities law, while representing plaintiffs in False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel can be reached through her website, www.rvrose.com.
Here are five ways you can mitigate the risk of a coding audit or fines in your practice, in relation to the coming ICD-10 conversion.
With the October 1, 2015 implementation date less than a year away, physicians should be well on their way to finalizing their ICD-10 transition plan. By now everyone familiar with ICD codes should appreciate that the more generalized ICD-9 code set is transitioning to the much greater specificity that comes with ICD-10-CM and ICD-10-PCS. Moreover, it is important to appreciate the key areas that need to be recognized and addressed. Below, I list five key items that should be considered; addressing these now can have positive implications later in the year.
1. Coordination with billers, practice managers, and EHR vendors.
Practice managers should make a checklist of who is involved in the claims processing cycle. The next step is to contact those entities, including billers and EHR vendors, to make sure that everything is in place for the transition, and that any field updates to the EHR system will be ready.
2. Payer preparation.
It is important that all your payers have been contacted either by you or your practice management company to make sure that the new codes you are submitting will be received. Otherwise, a delayed payment could result. Moreover, if there is a hybrid claim (i.e., the patient stay spans both ICD-9 and ICD-10 code sets) be certain is the payer has no problem with accepting that claim, or if they require submission of two different claims through different channels.
As with anything, preparation is key. Training ranges from billers being more familiar with anatomy and pathology to appreciating the specificity of documentation needed to substantiate a claim to meeting medical necessity under the CMS Guidelines. Also, many of the generic or "catch-all" codes available in ICD-9 are becoming non-existent.
4. Ramp-up period.
Any process, whether manufacturing or data entry, experiences an initial ramp-up period. This results in a decrease in both physician and staff productivity. Anticipate this occurrence because it can impact your practice's revenue stream.
5. Higher transaction costs.
In addition to the capital investment of an EHR system, there is a higher cost per transaction. This is due to a multitude of factors, including: training, claims processing costs, and rejections.
In sum, being proactive can reduce financial loss, time, and frustration in the future.