Effective October 1, physician practices and medical groups may experience increased claims rejections and payer denials following the conclusion of a one-year grace period established jointly by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association in 2015. "We expect carriers will reject claims containing unspecified codes and target these encounters for retrospective audits and revenue recoupments," says Renee Stamp, CPC, COC, CPC-1, CPMA, director of reimbursement for iHealth Innovations.
There are some legitimate times to use an unspecified code. For example, the provider may know the patient has pneumonia but the specific type is unknown until additional diagnostic testing is performed. This could be especially problematic for family practices who know a condition exists and assigns an unspecified code prior to additional tests being performed or consultation by a specialist. CMS states that providers should code each health care encounter to the level of certainty known for that encounter.
In addition to the conclusion of "relaxed rules" for ICD-10 coding on Part B claims, providers also must update their systems and staff on thousands of coding adjustments taking effect this Saturday. "Important changes are ahead for physician coding, and practices must be prepared," says Stamp, who advises the following steps before the October 1 deadline:
Three-Point Checklist for Physician Practices
1. Audit: Conduct an internal audit of all claims with unspecified ICD-10 codes to identify gaps or errors in physician documentation and coding. Check use of unspecified codes when documentation backs up a more detailed code. Also check EMR documentation templates and systems for ICD-10 code specificity and fiscal year 2017 updates.
2. Educate: Take appropriate remediation efforts based on audit findings. Provide training and education for every step in the revenue cycle, from front desk intake to claims submission. Ensure the coding on each claim aligns with the clinical documentation.
3. Monitor: Build a process whereby any staff receiving a payer denial or claims rejection due to coding communicates direct feedback to providers and practice managers. Focus on aligning specific ICD-10 codes to clinical documentation.
"It is important for practices and medical groups to review the fundamentals of compliant documentation, coding, and billing as they face this new set of ICD-10 challenges," Stamp says.
Source: iHealth Innovations