Let It Begin With You: ICD-10 Training for Physicians and Coders Reduces Rejected Claims

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Now that October 1 has come and gone, many of us in the healthcare world are breathing a sigh of relief that the move to the International Classification of Diseases and Related Health Problems 10th Revision (ICD-10) and its more complex codes appears now like our equivalent of the Y2K scare — much ado about nothing. For the most part, healthcare organizations used the grace year when implementation was pushed back from Oct. 1, 2014, to Oct. 1, 2015, to prepare for ICD-10’s massive code expansion. Recent reports cite successful implementation at 80 percent of surveyed healthcare organizations, with few reported technological snags and mostly uninterrupted claims processing across the board. 1

So is there a problem? Underneath the rosy trend reports celebrating a smooth transition, healthcare organizations who are struggling may be wondering what went wrong in their situation, and even those who navigated the transition without a ripple might find some issues lurking under the surface. For one thing, professional claims rejections have risen, and coder productivity has dropped almost 40 percent. Regardless of your size and the current success (or not) of your organization’s ICD-10 transition, it’s a good idea to make sure you and your professionals and partners understand all the changes, and why education can help bridge some of the remaining gaps.2

Insufficient Documentation from Physicians Matters More from ICD-9 to ICD-10
Most healthcare organizations prepared very diligently for the transition with years of ICD-10 training, ensuring that their technology was up to speed and that they were on the same page as any other providers and payers involved in their revenue cycle. Based on data coming from the first few months of ICD-10, one area where preparation may not have been as stringent involves physicians and documentation for professional claims.

Even the most diligent coding can result in a rejected claim if the original treating physician doesn’t understand his or her role in the claims process and can’t provide the level of detail in their documentation needed for coding a successful claim. Some client facilities have experienced as much as a four-fold increase in requests from coders to physicians for additional information — which you can imagine has an effect on physician productivity as well.

Especially for smaller providers and physician-owned practices, the lack of preparation from physicians has caused some anecdotal disruption to revenue cycles. While it has not yet been even four full revenue cycles since the implementation of ICD-10, healthcare industry observers have predicted for some time that coder preparation would far outpace physician preparation for the new code set which would cause issues during actual implementation. Larger hospital systems saw physicians rarely take advantage of educational offerings due to busy schedules or a feeling of being disconnected from the revenue cycle, and smaller providers focused more on other members of the revenue staff with their limited ability to fund large-scale education efforts.3

With so many codes under ICD-10 — 68,000 compared to ICD-9’s 13,000 — there is simultaneously greater specificity and greater opportunity for error for coders. In many cases, physician data is the only basis for determining a course in a complex coding situation. For physicians accustomed to doing a certain amount of case documentation under ICD-9, there will need to be some ICD-10 training to explain how the base of a claim — the documentation — will need to be much better now to support the increased complexity.4

If your organization is finding that insufficient documentation from physicians is causing problems for coders or a coding partner, gathering data may be the best way of educating physicians about this gap. Explaining that you’ve seen a strong uptick in queries for gestational diabetes mellitus, or that clinical documentation improvement and coding queries show a pattern of insufficient documentation, can help physicians understand their role in the revenue cycle, and how their actions directly affect the organization’s ability to have claims accepted in a timely manner.

In a physician-owned practice, the revenue cycle can be tied directly to physician pay, which makes the need for better documentation palpable. But even for employed physicians, better education about the need for more documentation due to the increased complexity of ICD-10 coding can make a seemingly administrative request feel more like a team effort. Of course physicians need to balance the needs of documentation for claims with patient time, but taking the holistic view, a better and more efficient revenue lifecycle leads to better ability for everyone to perform better patient care, after all.

Why More Coding Education Matters to Increase Productivity and Prevent Claim Rejections
On the surface, it makes complete sense that physicians could be the weak link in professional claims chain under ICD-10 — especially in small practices, physicians often wear more than one hat and may not have been able to properly prepare for the complexities of the new system. But every medical coder organization spent years preparing for the change, so why is coder productivity down and potentially adding to rejection of professional (and facility) claims?

The more doomsday-minded forecasters predicted a 50 percent reduction in coder productivity and most healthcare organizations have thus far seen much less than that, with the actual metric hitting somewhere between 5 and 35 percent in lost productivity. On the whole, this is a positive, a major setback that did not occur, but for most healthcare organizations, especially small ones, even a 10 or 15 percent loss in coder productivity can be devastating to the efficiency of your revenue cycle.5

Some of this can probably be attributed to the aforementioned issues with physician documentation, but there could certainly be other factors as well, ranging from general lack of preparedness to outsourced surge resources coming back to haunt well-meaning providers. For organizations who already engage in outsourced coding partnerships the low-cost surge resource may be significantly contributing to improperly coded and rejected claims, and coding productivity drops.

Some firsthand physician accounts note that some outsourced resources are ramping up staffing and forcing overtime spent in an effort to deal with the overage, with poorer quality coding an inevitable result. Additionally, many U.S. providers sent a high volume of ICD-9 coding work overseas as they worked with their internal staffs or domestic partners on getting up to speed for ICD-10, meaning that overseas coding operations experienced an onslaught of ICD-9 and ICD-10 work simultaneously. Coders are also more likely to have inadequate oversight and outdated books at overseas coding partners, all of which can affect quality of coding and ultimately, claims processed successfully.6

Working with lifecycle revenue partners like Physician Revenue Navigators is not a guarantee of successful short-term transition to ICD-10, of course. But working with a professional revenue optimization partner with PRN’s experience in all areas of healthcare vastly improves your organization’s ability to implement ICD-10 long-term. Because let’s not forget — these first few revenue cycles are just the beginning, and everyone from payers to physicians are adjusting to the new process. New challenges will certainly rear their heads in 2016.

At the KPMG ICD-10 transition event, 46 percent of surveyed healthcare executives stated that they are expecting to pursue initiatives in revenue cycle optimization in 2016.7 This is hardly surprising — revenue cycle is the lifeblood of an organization, and when the entire industry undergoes significant changes like ICD-10, the healthcare providers who are most successful at operations and providing excellent patient care are the ones who have solid, streamlined, consistently tested and optimized revenue cycles.

Physician Revenue Navigators is a leading healthcare revenue cycle management partner, supporting healthcare organizations in all aspects of a healthy revenue lifecycle, including coding, billing, accurate contractual adjustments, collections, HIPAA compliance and more. Contact us to learn more about how we can assist your organization in ICD-10 training for your physicians and coders.

Show 7 footnotes

  1. “ICD-10 Transition Successful at 80% of Organizations: KPMG Survey,” Nov. 30, 2015, http://www.kpmg.com/us/en/issuesandinsights/articlespublications/press-releases/pages/icd-10-transition-successful-at-80-of-organizations-kpmg-survey.aspx
  2. “ICD-10 Transition Successful,” Ibid.
  3. “Worrisome ICD-10 Fallout Seen in Smaller Hospitals,” Nov. 5, 2015, http://www.healthdatamanagement.com/news/worrisome-icd10-fallout-seen-in-smaller-hospitals-51509-1.html
  4. “Welcome to ICD-10,” Oct. 1, 2015, http://blog.cms.gov/2015/10/01/welcome-to-icd-10/
  5. “Coder Productivity Key as Advent of ICD-10 Unfolds,”
  6. “Offshore Coding: Week 1: Chaos,” Oct. 19, 2015, http://www.icd10monitor.com/enews/item/1514-offshore-coding-week-1-chaos
  7. “ICD-10 Transition Successful,” Ibid.

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