ICD-10 Grace Period Ending, What You Can Do to Prepare

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ICD-10 Grace Period Ending, What You Can Do to Prepare

The transition to ICD-10 last October went relatively smoothly. Clients of PrognoCIS have seen great benefits with the new ICD-10 coding, as providers using PrognoCIS medical billing software and revenue cycle management are having fewer claims rejected and are able to quickly receive more payments. Many coding-specific factors of PrognoCIS have contributed to this improvement, including:

  • Well-designed improvement of the user interface to accommodate frequently used codes
  • Quick and accurate access to the new codes as provided by the “drill down” features
  • Preparation of customers through PrognoCIS training webinars
  • A thoroughly pre-tested EHR and related systems infrastructure

However, the Medicare grace period for ICD-10 coding ends starting October 1, 2016. PrognoCIS has been ready for the transition (check out our ICD-10 Hub) for a while now. Let’s look at the ICD-10 grace period is, and what you can do to prepare for it.

What is the ICD-10 Grace Period?

As detailed in a post by HIMSS (Health Information and Management Systems Society), “for the first year of ICD-10 implementation, Medicare agreed not to deny reimbursement based solely on the ICD code specificity, as long as the ICD-10 code was a valid code from the proper ICD-10 code ‘family’, in other words, as long as the first 3 characters of the ICD-10 code were correct.” The Centers for Medicaid and Medicare Services (CMS) released an official FAQ when ICD-10 was released. Some of the important questions answered were:

  • When will the ICD-10 Ombudsman be in place?
    • In preparation for the transition, the ICD-10 ombudsman will be appointed by October 1st, ready to assess any potential issues.
  • What qualifies as a “valid” ICD-10 code?
    • In order to be considered valid, a code must include the “full number of characters required for that code.” CMS uses the example of Hodgkin’s lymphoma, for which this code requires 5 characters: C81.00.
  • What is a “family of codes”?
    • A “family of codes” is defined as the first three characters of the code. Continuing with our Hodgkin’s lymphoma example, this requires the characters: C81.
  • Will I know whether my claim was rejected because of validity or specificity?
    • According to CMS, the reason a claim is rejected (i.e. invalid code) will be made clear to submitters.
  • Will commercial payers observe the one-year flexibility?
    • The ICD-10 flexibility guidelines will only apply to Medicare claims. Commercial payers will determine flexibilities on their own.

Read our ICD-10 Guidelines blog here.

The End of the ICD-10 Grace Period, What You Can Do

The chief concern of the grace period  ending is claims processing. Everyone associated with the claims pipeline—from doctors all the way to insurers, will need to make sure their ICD-10 coding workflow is accurate.

How do you prepare for the grace period ending?

  1. Use electronic health record (EHR) software that works well with practice management software (PMS)

An integrated EMR/PMS system promotes interoperability and benefits everyone in the claims pipeline. PrognoCIS, which offers a toggle-able single-touch screen to switch between EMR/PMS, gives billers all the information required to process claims quickly and accurately. Better yet, if the EHR company has dedicated RCM staff (like PrognoCIS does) to handle your claims. The billers are then intimately familiar with both the billing and medical side of the software, which means zero times for training or implementation, and quicker claims.

On the clinical side, an integrated solution allows doctors to review the financial side of their practice, not just the medical records. Doctors who contract with a 3rd party biller are not able to see their claims/accounts receivable (AR)—essentially leaving them blind to their finances. With an integrated solution, clinicians can check their claims/AR at any time, giving them peace of mind as well as better control over their finances.

Read more about the benefits of an integrated EMR/PMS system here.

  1. Use an EHR that has claims processing in mind

A great integrated EMR/PMS suite has claims processing in mind, and offers a user interface which  allows you to search for ICD-10 codes easily, and save the most used codes. PrognoCIS is a Meaningful Use certified and ICD-10 compliant solution designed to help billers process claims quickly. One valuable feature of our client is our internal scrubber checks, which “clean” your claims before they are sent to the clearinghouse. Scrubber checks are checkpoints a biller can create to ensure claims are processed correctly. Billers create a procedure where “checks” are created so information is valid before you can move on.

We illustrate a simple example of a scrubber check in PrognoCIS which stops a biller from processing a

PrognoCIS Scrubber Check
PrognoCIS Scrubber Check

claim unless it meets the requirements:

  1. Reexamine clinical processes related to ICD-10 codes

With the grace period ending, it is imperative to look at all workflow associated with ICD-10 coding. This comes in the form of reviewing reports on the top ICD-10 codes used, in particular look at ones which may be unspecific (penalized after the end of the grace period). Analyze diagnosis codes by both clinician and biller to see if there are any trends in coding which may be ambiguous.

Clinical documentation must also be looked at. Christine Lee, MHA, RHIA, CCS, CPC, of the AHIMA (American Health Information Management Association), points out it’s important to review documentation:

  • If more specific diagnosis codes can be assigned based on the documentation, provide education to the appropriate staff on proper code assignment
  • If documentation is not complete for desired level of diagnosis specificity, provide clinical documentation improvement education to clinicians.

She notes that while it may be ok to enter unspecified ICD-10 CM codes, it is the exception, not the rule. Practices who submit unspecified codes after the end of the grace period by mind “an increase in post payment audits and quality reporting errors. As audits increase, so will payer requests for medical records and clinical documentation.”

What the Future Holds for ICD-10

As Christine notes, along with the end of the grace period clinicians face two final coding challenges: a myriad of new ICD-10 codes and a substantial review process unspecified ICD-10 code usage. New—almost 2000 ICD-10-CM codes—are scheduled to come from an “unthawing” of updates to codes. As the CMS (Centers for Medicare and Medicaid Services) notes, the last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, 2011. Since then, the only updates were to account for new technologies and diseases. Starting October 1, 2016, after the grace period ends, regular updates to ICD-10 codes are scheduled to begin.

The substantial review process consists of unspecified ICD-10 codes to new more specific ones that will be used in 2017. Clinicians must review all documentation regarding coding, whether it is financial or medical, to truly prepare for the end of the grace period. Along with the aforementioned tips, it may be useful to hire a coding professional to help with the new ICD-10 codes.

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Picture Credit: Thibault J./Flickr