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What the end of the ICD10 grace period means for your hospital [PODCAST]

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In this episode, Stacey Straz, Senior Consultant in the Compliance and Coding Audit team at BESLER Consulting  is here to talk to us about the end of the ICD-10 grace period and what it means for your hospital.
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Michael Passanante:   Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast. We are very happy you could be with us.

Today, I am joined by Stacey Straz who is the Senior Consultant in our Coding and Compliance Audit Team here at BESLER Consulting. Welcome Stacey.

Stacey Straz: Hi, Mike.

Michael: So Stacey is here to talk to us about the importance of the end of the ICD-10 grace period. So we are going to walk through that shortly.

But Stacey, can you quickly just recap and explain for the audience the process in which ICD-10 codes are assigned?

Stacey:  Yes, I can. ICD-10 codes are disease classification codes. They are selected based upon the provider’s clinical documentation. ICD-10 has more than 68,000 codes where previously there were approximately 13,000 ICD-9 codes.

Providers are urged to document conditions to the highest specificity possible so that the appropriate diagnosis codes are supported and in turn submitted on the provider’s claims. In the event that the provider does not know the exact diagnosis, providers are directed to code the documented signs and symptoms for the encounter.

Michael: Great. Thanks for that background, Stacey. So jumping into the topic for today, can you explain for the audience what the unspecified ICD-10 grace period is?

Stacey: The ICD-10 grace period was a joint effort between the Centers for Medicare and Medicaid and the American Medical Association to allow for a smoother transition from the I-9 diagnosis coding to the I-10 diagnosis coding.

The grace period was one full year from the ICD-10 implementation date of October 1st, 2015 to October 1st, 2016, in which unspecified ICD-10 codes were permitted as acceptable codes on claim submissions. This grace period indicated that providers could submit codes that were not coded to the highest level of specificity and they would not receive denials on their claims.

Generally, commercial payers follow suit with CMS guidelines, but some payers may not have accepted the unspecified codes as soon as the start date of October 1st, 2015.

Michael: Okay. So which providers are impacted by the end of the ICD-10 unspecified code grace period?

Stacey: All providers who bill fee for service are affected. There can be major financial impact for individual group practices as well as hospital contracted physicians such as leased or employed physicians.

Some providers are tasked with documenting specificities in their specialty more than others based upon the types of conditions they treat. An example would be providers who treat conditions that can be laterality specific. It would have to include the site of the body where they are treating in their documentation.

But generally, all specialties have unspecified code selections and if they report those to CMS and commercial insurance carriers, they will trigger denials on their claims.

Michael: So when is it okay to choose an unspecified ICD-10 diagnosis code?

Stacey: It would be appropriate for coding professional to select an unspecified ICD-10 code when the provider’s documentation does not support a more specified code. Providers who are in uncertain specificity of a disease or condition, their treating would select an unspecified code until the diagnosis is confirmed.

For example, this is found with pneumonia. A provider may not have lab results to confirm the bacteria organism type designated in the ICD-10 codes selection and they won’t be able to document to the highest specificity until the pathology results are available. Again, providers are advised to code the signs and symptoms when a confirmed diagnosis is not available.

But in both of these scenarios, the insurance carrier would still deny the claim due to the use of the unspecified diagnosis codes. So, coding professionals are urged to query providers for more specific diagnoses.

Providers may have to wait to submit their claims until they have a confirmed diagnosis. If that is not an option, code the symptoms until pathology or diagnostic workups confirm a more specific diagnosis in order to avoid claim denials.

Michael: So Stacey, what is the effect of submitting unspecified ICD-10 codes on providers?

Stacey: Providers who do not document to the highest specificity possible and report the most specific ICD-10 diagnosis codes on their claims, they can anticipate insurance denials. These denials create a great slow down in reimbursement for providers and result in costly claim resubmissions and appeals in some cases.

Insurance carriers may view these submissions of unspecified codes after October 1st, 2016 as red flags as well and order the providers documentation and coding, again resulting in a loss of time and the use of office staff resources. Audits can result in sanctions and possible recoupments.

Michael: Stacey, can coding professionals assign specified ICD-10 diagnosis codes when the provider has not indicated the specificity in order to get claims paid?

Stacey: No. It would not be appropriate to choose specified codes that are not supported in the provider’s documentation. Coding professionals who are assigning codes for providers are directed to choose and report unspecified codes in the absence of documentations, which support more specified codes.

As I stated earlier, coders should be directed to query the provider rather than select a specified code that’s not documented. In the case where the provider is queried for more specific documentation, the provider would want to make an addendum to their documentation to support the highest level of specificity for the diagnosis.

Coders who assign codes that are not supported in the documentation create a compliance risk and at the event that those records were audited an insurance carrier may recoup money from that provider.

Michael: So what indicates an ICD-10 as unspecified?

Stacey: Unspecified ICD-10 codes typically end with a numeric digit nine and they have a bold notation in the ICD-10 code book as being unspecified.

Michael: Stacey, how can providers transition from reporting unspecified ICD-10 codes to more specified codes?

Stacey: As with the inception of the ICD-10, providers were encouraged to make a list of their most frequently used ICD-9 codes, cross-walk those codes over and convert them into I-10 diagnosis codes.

A good practice would be to list the most utilized unspecified diagnosis codes and research the higher specificity ICD-10 codes available in that code set. Also providers and coding staff can familiarize themselves with the chapter-specific coding guidelines in the front of each chapter in the ICD-10 coding book. These guidelines offer explanations, list site and laterality designations and advice on sequencing priority.

Using outside consultants with experience in proper documentation guidelines and ICD-10 proficiency can often save providers time and money in the long run by educating themselves and the staff on the specific guidelines. Having provider -specific education that stresses the importance of these points is crucial.

Providers can utilize consultants to ensure clean claim submission, eliminate costly denials and keep a steady revenue flow.

Michael: Stacey, this is my last question for you. What can healthcare professionals do to avoid claim denials due to the submission of unspecified ICD-10 diagnosis codes?

Stacey: In order to ensure clean claim submission and timely payment from the insurance contractors, providers are urged to evaluate their ICD-10 code reporting prior to October 1st, 2016 and ensure that their documentation supports diagnosis coding to the highest specificity.

Familiarize yourself with the ICD-10 codes in your provider’s specialty. And make sure coding and billing staff understand the importance of querying providers for more specific documentation and encouraged to do so.

Michael: Stacey, I believe there are some additional resources available on the Medicare website.

Stacey: That’s correct, Mike.

Michael: Great. So we will have those resources listed on the blog post for this particular podcast. So you can link to them and read more about this unspecified grace period and what it means for you.

Stacey, thanks for coming by today and helping us understand more about this topic.

Stacey: Thank you, Mike.

Michael Passanante:   Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast. We are very happy you could be with us.

Today, I am joined by Stacey Straz who is the Senior Consultant in our Coding and Compliance Audit Team here at BESLER Consulting. Welcome Stacey.

Stacey Straz: Hi, Mike.

Michael: So Stacey is here to talk to us about the importance of the end of the ICD-10 grace period. So we are going to walk through that shortly.

But Stacey, can you quickly just recap and explain for the audience the process in which ICD-10 codes are assigned?

Stacey: Yes, I can. ICD-10 codes are disease classification codes. They are selected based upon the provider’s clinical documentation. ICD-10 has more than 68,000 codes where previously there were approximately 13,000 ICD-9 codes.

Providers are urged to document conditions to the highest specificity possible so that the appropriate diagnosis codes are supported and in turn submitted on the provider’s claims. In the event that the provider does not know the exact diagnosis, providers are directed to code the documented signs and symptoms for the encounter.

Michael: Great. Thanks for that background, Stacey. So jumping into the topic for today, can you explain for the audience what the unspecified ICD-10 grace period is?

Stacey: The ICD-10 grace period was a joint effort between the Centers for Medicare and Medicaid and the American Medical Association to allow for a smoother transition from the I-9 diagnosis coding to the I-10 diagnosis coding.

The grace period was one full year from the ICD-10 implementation date of October 1st, 2015 to October 1st, 2016, in which unspecified ICD-10 codes were permitted as acceptable codes on claim submissions. This grace period indicated that providers could submit codes that were not coded to the highest level of specificity and they would not receive denials on their claims.

Generally, commercial payers follow suit with CMS guidelines, but some payers may not have accepted the unspecified codes as soon as the start date of October 1st, 2015.

Michael: Okay. So which providers are impacted by the end of the ICD-10 unspecified code grace period?

Stacey: All providers who bill fee for service are affected. There can be major financial impact for individual group practices as well as hospital contracted physicians such as leased or employed physicians.

Some providers are tasked with documenting specificities in their specialty more than others based upon the types of conditions they treat. An example would be providers who treat conditions that can be laterality specific. It would have to include the site of the body where they are treating in their documentation.

But generally, all specialties have unspecified code selections and if they report those to CMS and commercial insurance carriers, they will trigger denials on their claims.

Michael: So when is it okay to choose an unspecified ICD-10 diagnosis code?

Stacey: It would be appropriate for coding professional to select an unspecified ICD-10 code when the provider’s documentation does not support a more specified code. Providers who are in uncertain specificity of a disease or condition, their treating would select an unspecified code until the diagnosis is confirmed.

For example, this is found with pneumonia. A provider may not have lab results to confirm the bacteria organism type designated in the ICD-10 codes selection and they won’t be able to document to the highest specificity until the pathology results are available. Again, providers are advised to code the signs and symptoms when a confirmed diagnosis is not available.

But in both of these scenarios, the insurance carrier would still deny the claim due to the use of the unspecified diagnosis codes. So, coding professionals are urged to query providers for more specific diagnoses.

Providers may have to wait to submit their claims until they have a confirmed diagnosis. If that is not an option, code the symptoms until pathology or diagnostic workups confirm a more specific diagnosis in order to avoid claim denials.

Michael: So Stacey, what is the effect of submitting unspecified ICD-10 codes on providers?

Stacey: Providers who do not document to the highest specificity possible and report the most specific ICD-10 diagnosis codes on their claims, they can anticipate insurance denials. These denials create a great slow down in reimbursement for providers and result in costly claim resubmissions and appeals in some cases.

Insurance carriers may view these submissions of unspecified codes after October 1st, 2016 as red flags as well and order the providers documentation and coding, again resulting in a loss of time and the use of office staff resources. Audits can result in sanctions and possible recoupments.

Michael: Stacey, can coding professionals assign specified ICD-10 diagnosis codes when the provider has not indicated the specificity in order to get claims paid?

Stacey: No. It would not be appropriate to choose specified codes that are not supported in the provider’s documentation. Coding professionals who are assigning codes for providers are directed to choose and report unspecified codes in the absence of documentations, which support more specified codes.

As I stated earlier, coders should be directed to query the provider rather than select a specified code that’s not documented. In the case where the provider is queried for more specific documentation, the provider would want to make an addendum to their documentation to support the highest level of specificity for the diagnosis.

Coders who assign codes that are not supported in the documentation create a compliance risk and at the event that those records were audited an insurance carrier may recoup money from that provider.

Michael: So what indicates an ICD-10 as unspecified?

Stacey: Unspecified ICD-10 codes typically end with a numeric digit nine and they have a bold notation in the ICD-10 code book as being unspecified.

Michael: Stacey, how can providers transition from reporting unspecified ICD-10 codes to more specified codes?

Stacey: As with the inception of the ICD-10, providers were encouraged to make a list of their most frequently used ICD-9 codes, cross-walk those codes over and convert them into I-10 diagnosis codes.

A good practice would be to list the most utilized unspecified diagnosis codes and research the higher specificity ICD-10 codes available in that code set. Also providers and coding staff can familiarize themselves with the chapter-specific coding guidelines in the front of each chapter in the ICD-10 coding book. These guidelines offer explanations, list site and laterality designations and advice on sequencing priority.

Using outside consultants with experience in proper documentation guidelines and ICD-10 proficiency can often save providers time and money in the long run by educating themselves and the staff on the specific guidelines. Having provider -specific education that stresses the importance of these points is crucial.

Providers can utilize consultants to ensure clean claim submission, eliminate costly denials and keep a steady revenue flow.

Michael: Stacey, this is my last question for you. What can healthcare professionals do to avoid claim denials due to the submission of unspecified ICD-10 diagnosis codes?

Stacey: In order to ensure clean claim submission and timely payment from the insurance contractors, providers are urged to evaluate their ICD-10 code reporting prior to October 1st, 2016 and ensure that their documentation supports diagnosis coding to the highest specificity.

Familiarize yourself with the ICD-10 codes in your provider’s specialty. And make sure coding and billing staff understand the importance of querying providers for more specific documentation and encouraged to do so.

Michael: Stacey, I believe there are some additional resources available on the Medicare website.

Stacey: That’s correct, Mike.

Michael: Great. So we will have those resources listed on the blog post for this particular podcast. So you can link to them and read more about this unspecified grace period and what it means for you.

Stacey, thanks for coming by today and helping us understand more about this topic.

Stacey: Thank you, Mike.

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