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The upcoming coding change requires reimbursement monitoring by practices and perhaps a review of claims appeal processes as well.
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.
Preparing for Life After ICD 10
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.
Claims Reconciliation/Payer Contracts
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." (For more information, visit bit.ly/CMS-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. (For more information, visit bit.ly/Medicare-appeals-process.)
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.
Potential Reimbursement Delays
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;
• Mapping and crosswalk delays;
• 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.
Patricia Buttner, RHIA, 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 Patricia.Buttner@ahima.org.
This article originally appeared in the September 2015 issue of Physicians Practice.