Now What? The Biggest Challenges of the ICD-10 Transition Could Still Lie Ahead

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We sometimes use a pie analogy when working with clients on all the different aspects of revenue cycle management. It helps our clients train their staff if they understand the different steps and how everything must work together and be timed correctly to get a good result. This holds true whether we’re talking about a delicious, made-from-scratch pie or a healthy revenue cycle. When it came to working with providers on October 2015’s ICD-10 implementation, we once again found ourselves breaking out the pie analogy.

Just Getting Started

Preparing for ICD-10 was like getting a ton of ingredients together and making the pie crust, a good foundation for the rest of the pie and a complex operation in and of itself. But it’s too soon for everyone to celebrate a job well done, especially smaller organizations or physician-run offices with small margins that rely on payments from narrow payment sources.

We’ve heard all the analogies comparing ICD-10 implementation to a Y2K-esque much ado about nothing. We’re not advocating a return to the panic that gripped the industry for years ahead of the change. (Honestly, we’ve never been fans of that frenzy because we always work with our clients to prepare for any big shifts like this). Still, it is important for CFOs and other health care executives to realize that there is still plenty of work to be done.

The Grace Period with Payers Will End Soon

The Centers for Medicare and Medicaid Services (CMS) has stated that it would give providers a 12-month grace period after ICD-10 implementation. Until Oct. 1, 2016, CMS will not reject claims as long as they are coded in the correct family of ICD-10 codes, and will not reject any claims for lack of specificity—the heart of ICD-10’s expanded codes. Most private payers followed suit, and rejection percentages have held relatively steady throughout the first few cycles after Oct. 1.

After Oct. 1, 2016, however, CMS will begin expecting more precise codes and use of the most appropriate diagnosis codes. Private payers are under no obligation to continue their grace periods as long, and many industry watchers expect them to begin tightening up their reporting and coding requirements much sooner than CMS.

This is the biggest reason why the current comfort level with the transition may not last.

Let’s go back to our pie analogy to put this into perspective. Imagine you’ve been following a simple recipe to prepare a pie. It’s an easy recipe, and you haven’t checked it too carefully. Suddenly, you realize you’ve been following the wrong recipe, and now you must switch to a much more complicated recipe and produce a pie in half the time. It would have been better to use the complicated recipe from the get-go.

We’ve previously discussed why working with your payers can pay dividends down the road in preparing for tightened requirements, but it’s important to reinforce that “down the road” could be as soon as next year. We’ll be working with our clients throughout 2016 to carefully track rejected claims percentages to look for an uptick in these types of rejections.

2016 May Be the Year You Really Need ICD-10 Training and Audits

Revenue cycle management is like baking a pie from scratch—it’s a complex process with a lot of moving parts. Image source: Flickr CC user Arek Olek
Revenue cycle management is like baking a pie from scratch—it’s a complex process with a lot of moving parts.
Image source: Flickr CC user Arek Olek

When the first and second revenue cycles after Oct. 1 came and went without too much disruption to our systems and payments, many of us in the health care industry breathed a sigh of relief. We’ve heard some providers mention that now they can discontinue educational programs or cut back on working with revenue cycle management experts on optimization for ICD-10 because “the worst has passed.”

In reality, the ICD-10 education your team receives in 2016 could be equally, or even more, important than all the training leading up to the implementation. Being able to use live examples and immediately put training into action means that your staff may get more out of ICD-10 refresher courses than their original training.

You may be baking your pie the same way for years and continue to hear great feedback, until one day a new judge at the fair says you still have room for improvement. Similarly, your coders may be using non-specific codes and experiencing no issues, even after ICD-10 arrived. Everyone might think everything is fine—until the grace period ends for CMS and private payers. Suddenly, your coders may be forced to use more specific codes. If you abandoned their educational programs months before that, because Oct 1, 2015 has passed, they might have difficulty adjusting to new requirements.

The same goes for physician education for clinical documentation, which will help coders avoid the pitfalls of trying to code more specifically than the existing documentation. Do your physicians know that malignant hypertension is gone from ICD-10 and they should adjust their documentation accordingly? Do your EMTs know that information about the Glascow coma scale can now be taken from their documentation, and are they being trained accordingly?

Do your coders know that metabolic encephalopathy (G94.14) is now an accepted code for patients who suffer from hypoglycemic-induced confusion as a result of diabetic hypoglycemia? Keeping your staff current on all of these changes with continuing education takes way less effort than starting from zero again after the CMS and private payer grace period comes to an abrupt end.

Medical revenue management, like creating a perfect pie, is a complex process with a lot of moving parts. If you haven’t done an audit of your systems just before moving to ICD-10 or afterward, consider doing so now to ensure that as payer requirements tighten, your physician, staff, and coders are ready. Working with professionals trained in assessing gaps and optimizing revenue cycle can have an enormous benefit for organizations of all sizes. We’d all like to learn pie-making from a professional chef, after all.

Physician Revenue Navigators is a premier provider of revenue management for health care entities. Contact us to learn more about how ICD-10 might impact your revenue and reimbursements, and how the right revenue lifecycle management partner can optimize your health care organization’s operations.

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