also help identify providers who will benefit from focused training on ICD-10-CM.
Revenue and Cash Flow Considerations
Most commercial insurance carriers have indicated they will
“crosswalk” ICD- 10 codes back to ICD- 9 codes for payment
purposes. This allows them to avoid expensive reprogramming
of all their payment systems; however, it also creates an opportunity for confusion and claim processing errors. In addition,
some industry skeptics have voiced concerns about possible
mischief and intentional denials resulting from this practice.
Physician practices will be wise to include ICD- 10 in their
payer contract negotiation discussions over the next two years
to decrease their risks concerning compliance errors and claims
denials. In the period following ICD- 10 implementation, payers
will have little choice but to continue prior reimbursement policies. As the implications of the ICD- 10 code sets become apparent, so too will the implications for greater payment for greater
complexity and lower payment for lesser complexity.
An audit of current documentation
practices will help create a
prioritized list of diagnoses
that will require more detailed
documentation under ICD-10-CM.
Since reimbursement is tied to procedural and diagnosis coding, the practice’s finances will be affected significantly by the
transition. For example, after the implementation date, if an insurance carrier cannot accept ICD-10-CM codes, the practice
most likely will not be paid by that insurer.
For this reason it is imperative for the practice to know which
payers have fully transitioned to ICD-10-CM and which have
not, so it can prepare the billing accordingly and ensure proper
and prompt payment.
Practices can use the data from their documentation audit to
review the current reporting for procedures and services using
ICD-9-CM and compare them to ICD-10-CM codes. Professional services are paid based on the procedure code, but the
diagnosis code supports medical necessity—the driving factor
in payment for all medical procedures and services.
Additional points the practice should consider that will affect
physicians and their practices include:
The documentation audit will also assist practices in deter-
mining the potential impact the transition may have on revenue
by payer or contract and the potential opportunities that ICD-
10 can bring. The practice should also consider potential risks
Practices should prepare for a potential disruption of cash
flow. Based on experience with HIPAA transaction code imple-
mentation, many groups anticipate similar problems with Med-
icaid programs. In fact, it is likely this will be more substantial
because Medicaid is undergoing expansion under healthcare
Considerations for EHR Implementations
The changes in documentation and coding that ICD- 10 requires
make the transition a strategic time to implement or upgrade
an EHR system. For practices that decide to do so, there are a
number of factors they should carefully consider when selecting a system.
The adoption of an EHR is a major operational change, especially for physicians. Practices must allow physicians sufficient
time to be fully trained and functional on the EHR. It can take
many months for clinicians to fully adapt to working with the
system and recover from the loss of productivity that normally
accompanies an EHR implementation. If the EHR is not carefully selected and properly implemented, physician productivity may never recover.
Practices should consider the following questions when con-
sidering a new or upgraded system:
As the deadline draws near, demand for hardware, software,
implementation, and training support will quickly exceed sup-
ply, and costs for consultants and talent will sky rocket.