Nothing Lasts Forever: How Physicians Can Prepare for the End of the One-Year Amnesty from Post Payment Reviews Due to Unspecified Codes
By Christine Lee, MHA, RHIA, CCS, CPC
Just as ocean tides shift with the earth's gravitational pull, physician practice administrators align staff and focus resources to address their organizations' most pressing concerns. This year, the tsunami grabbing administrators' attention is the conclusion of a one-year grace period for ICD-10 post payment reviews related to code specificity in claims filed under the Medicare Part B physician fee schedule.
While the correct level of ICD-10 code specificity has always been required for National Coverage Determinations, Local Coverage Determiniations, other claims edits, prepayment reviews, and prior authorization requests, physicians were granted amnesty from post payment reviews due to unspecified codes. This grace period concludes on October 1, 2016.
This article summarizes three areas for physician practices to address before the final phase of ICD-10 implementation comes ashore.
Mitigate Risk of Unspecified ICD-10 Codes
Proactive practices are already conducting internal audits to identify trends in unspecified clinical documentation and diagnosis code assignment. A three-step process can then be utilized:
1. Review reports of top ICD-10 diagnosis codes, paying particular attention to identify unspecified codes.
2. Conduct analysis of diagnosis codes assigned by clinician and/or coder to identify any patterns or trends in unspecified ICD-10-CM (diagnosis) coding.
3. Review clinical documentation:
a. If more specific diagnosis codes can be assigned based on the documentation, provide education to the appropriate staff on proper code assignment.
b. If documentation is not complete for desired level of diagnosis specificity, provide clinical documentation improvement education to clinicians.
While there are a few instances where usage of unspecified ICD-10-CM codes may be appropriate, widespread use of numerous unspecified codes should be the exception, not the rule. Practices submitting unspecified ICD-10 codes after October 1, 2016 may potentially experience an increase in post payment audits and quality reporting errors. As audits increase, so will payer requests for medical records and clinical documentation.
A spike in medical record requests by payers is a trigger for medical practices to conduct in-depth clinical documentation and coding audits as mentioned above. However, failure to submit requested clinical documentation upon payer request also leads to the practice not getting paid for those claims, and an increased suspicion by auditors.
Hire a Credentialed Coding Professional
Physician practices are also re-evaluating the importance of a credentialed clinical coder to tighten ICD-10 coding practices and establish a compliance coding program. Trained coding professionals evaluate electronic medical record (EMR) code assignments, identify software errors, and conduct advanced ICD-10 training for non-specific documentation and coding problem areas.
However, for many smaller practices, hiring a full-time, credentialed coding professional may be cost prohibitive. In this case, the following four strategies may be effective:
Partner with another practice to share the cost.
Employ a certified coding professional via a contract arrangement or consulting engagement.
Select a current staff member to complete coder training and certification, using the training as an internal career advancement opportunity.
Bring in an interim coding professional to prepare for the final phase of ICD-10 implementation, improve clinical documentation specificity, and investigate EMR software glitches.
Check EMR Software
Since the 2015 CMS and AMA announcement regarding unspecified ICD-10 codes, physician practices have tended to maintain the status quo—relying on EMR software to suggest correct ICD-10 codes.
Some glitches in EMR software and encoder decision trees have been reported. These errors, if left uncorrected, lead to claims rejections and reimbursement delays. Examples of specific encoder software issues that have been identified include these three ICD-10 diagnoses areas:
Motor vehicle accidents
Traumatic fractures, tibia spine
Physician practices face two final coding challenges in the year ahead: a plethora of new ICD-10 codes and year-over-year statistical reporting inconsistencies. October 2016 brings a flood of new ICD-10 codes as CMS thaws a three-year partial code freeze. Physician practices must prepare for the addition of nearly 2,000 new ICD-10-CM codes. While no individual physician practice uses all of the new codes, each specialty should carefully review the changes ahead, focusing particularly on the subset of codes applicable to their practice or patient population.
Finally, practices will face statistical reporting challenges as unspecified ICD-10 codes used in 2016 must be compared against more specific ICD-10 codes in 2017.
A proactive approach to mitigate unspecified documentation, coding, and billing is the best remedy for post-grace period concerns. Now is the time for practices to consider hiring credentialed coding professionals and/or partnering with coding consultants. HIM professionals will become increasingly valuable as physicians prepare for the new wave of coding challenges ahead.