The Data Scientist - the WPC Healthcare Blog

Preparing for ICD-10: Business Process Impacts


By Becca Harris

The impact of ICD-10 on providers will vary depending on facility type and location. Small offices will typically have deeper impacts due to lack of resources and funds. Regardless of the size of your office, the first thing you need to put in motion is selecting an implementation team. This team should include one top resource from each area in the office, including a nurse or medical assistant. The implementation team’s top priority is to create a timeline and revisit that timeline on a weekly basis to make sure the organization is on track to meet the demands of ICD-10. I highly recommend creating multiple checklists, one for each department. The best way to be prepared for ICD-10 is to pretend that it is occurring in present day. My list of impacts highlight areas that are of high importance and how to monitor them after October 1, 2014.

The following is the top 10 areas I recommend that providers should monitor with regards to ICD-10 (click here for a diagram of the general ICD-10 claim flow):

  1. Central Scheduling and Confirmation of Benefits — All medical and office staff need to use and understand new Superbills and all internal and external forms that have been updated. Superbills set the foundation for accurate billing, coding, and reimbursement. ICD-10 CM will not affect fee schedules since fees are typically assigned to CPT codes, however, ICD-10 CM will affect medical necessity. A good rule of thumb is if an ICD-9 code affected pricing or coordination of benefits, or if it required a referral or pre-authorization, the new code will require the same amount of effort, if not more. Post 10-01-14: Monitor your front office by paying attention to insurance denials and by re-evaluating the efficiency of new forms or revised forms.
  2. Advanced Beneficiary Notice (Medicare) — Staff will need enough education to determine when an ABN needs to be signed prior to medical services being rendered. An unsigned ABN results in a free visit or a very upset patient. Post 10-01-14: Monitor your Medicare denials closely. I suggest that you flag your denials due to ABNs and re-educate your office staff immediately.
  3. Pre-Registration/Financial Counseling for Surgical Services — Coding done in a surgeon’s office will directly affect the hospital’s claims and all surgical staff who select their codes based on the surgeon’s codes and documentation. If the surgeon codes the claim incorrectly, it will cause a delay in reimbursement for all involved parties. Post 10-01-14: Monitor this area of your office by having a second set of eyes review all scheduled surgery codes prior to the date of service.
  4. Coding and Billing — Staff will need strong ICD-9 and ICD-10 coding skills to perform forward and backward mapping. Coders need to understand the new coding logic, coding rules and anatomy physiology. Post 10-01-14: Monitor your coding and billing department by performing random monthly audits and paying close attention to denials and AR days.
  5. Contract Negotiations — ICD-10 will open provider contracts not originally slated to open for renegotiation. This is an opportunity for providers to renegotiate contracts and hopefully take steps to recoup some of the ICD-10 implementation costs. Post 10-01-14: Monitor your contracted rate by running month-end reports that show billed vs. paid amount. Pay close attention to your contractual write off amounts.
  6. Appeals — Appeals department staff will need a strong knowledge in ICD-10 codes and documentation requirements in order to file disputes for under-payment or denials. Post 10-01-14:Monitor your appeals department by monitoring the number of appeals overturned.
  7. Revenue Cycle — Managers need a strong understanding of how ICD-10 CM affects reimbursement. Managers should monitor their AR days and work closely with software vendors to take advantage of all automated tools that will flag under- and over-payments and track payer turnaround time. Claims staff should be aware of filing and appeal limits. Analysis is the most essential component of a good biller. I highly suggest that your office treats their September month-end billing as if it is December 31 and not September 31. Have a clean slate on October 1 by having all your claims out the door and your books balanced. Post 10-01-14: Managers should pay close attention to coders who are struggling with the new code set and be prepared to offer tools to aid them with accurate coding and to prevent claim backlog. Utilize your medical management software to its fullest. Most software comes with a great deal of month-end reports that should be used to track AR. If your software does not come with reports, I highly suggest purchasing more inclusive software as part of your implementation.
  8. Collections — The amount of uncollected dollars transferred to private pay is going to increase due to either coding errors, billing errors, or insurance limitations. The granular level of coding will likely spark pre-existing conditions, insurance limitations, and unpaid claims due to diagnosis codes that indicate a cosmetic service and/or uncovered diagnosis. A well trained front office staff is vital in preventing unpaid claims, insuring patients sign financial agreements, and capturing accurate patient demographic information.
  9. Clinical Documentation —The golden rule for ICD-9 will stay the same for ICD-10: “If an ICD-10 CM code is not supported by documentation, it cannot be billed.” A thorough CDI process and analysis will identify current ICD-9 codes frequently used. These codes can then be used to build a modeling map specific to each provider. A doctor should be queried when there is a conflicting or incomplete documentation relating to a patient’s diagnosis or procedure. Be careful that your queries are not limited to reimbursement factors only, as this may be misinterpreted as up coding if your office is audited. It is a good idea to get your physicians used to coding at a more granular level now so they are already used to the extra work involved when ICD-10 requirements come knocking on the door.Post 10-01-14: Monitor clinical documentation through monthly audits.
  10. Budget — Planning a budget to cover implementation costs and post-implementation costs can be overwhelming and difficult. Plan to spend most of your training budget on your coders and any software upgrades. Post 10-01-14: Monitor your budget very carefully during the entire implementation process. Contact vendors well in advance to inquire about costs associated with upgrades. If your office is planning on hiring a consultant to assist with ICD-10, make sure the fee includes travel expenses and budget accordingly.

There are so many resources on the internet to help you get ready for the big day, October 1, 2014. Remember to check the CMS website frequently for any news, tips, checklists, and recommendations. Only rely on healthcare experts when it comes to ICD-10 to avoid being misinformed. If you are planning to use an outside resource, such as a project manager or consultant, I highly advise that you engage in a contract as soon as possible. Email me directly or contact me through LinkedIn, and I can put you in contact with a resource to help you with your ICD-10 staffing needs.