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The Pulse on ICD-10 Conversion – What’s Going On / What Next?

Reading about the ICD-10 conversion you can find many articles out there today. These range from “I told you so” type articles to looking at some of the ins & outs and early lessons learned in the first business quarter, since the mandated implementation took place on 1 October 2015. That said, there are some mixed messages regarding implementation success.

Outpatient Medical Coding and Billing

For example, the Coalition for ICD-10 reports that “Some healthcare providers are reporting a few ICD-10 denials but not enough to worry about. On the other hand, reported that a healthcare consultant found out that a California HMO was denying medical claims on a massive scale. Additionally, National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) have needed tweaks to prevent mistaken denials.

So if you don’t consider coverage denials a major national problem, it certainly can be categorized as a major problem for individual medical practices. So there are fixes still required for the new system.

ICD10Watch published a very helpful article that talks about 3 keys to success in this new ICD-10 environment.  Those keys included:

  1. Measure ICD-10 claim denials and monitor revenue-based metrics. It is important to understand where the problems are occurring. Then medical practices can start fixing the problems that create denials.
  2. Figure out if the right ICD-10 codes are being used.  There is lots of room for error so make sure the medical claims are coded correctly and clinical documentation supports the diagnoses. Keep investing in coding training.
  3. Keep calling the healthcare payers until they answer questions. Do not let any denial go because it’s too much work.

Best advice: How to Prevent Denials

Chris Nerney at Revenue Cycle Insights had a great article that identifies three things that can help healthcare providers prevent claims denials:

  1. Registration processes: Denial problems can start before the first ICD-10 code is recorded.
  2. Medicaid: This comprises 13% of all denials. Start by checking eligibility, medical necessity, and pre-authorization.
  3. High-impact specialties: Specialties contribute heavily to major amounts of claim denials. (Repeat the advice in the first two tips).

In a way, the macro level claim denial statistics don’t matter as much as the individual anecdotes. Those stories are valuable examples of how to solve denial issues.

One of the best insights of the article was the advice that, “Waiting to find out how the ICD-10 transition went is a bit like using the rear view mirror to drive a car.” So they recommend that you keep your eyes on the road ahead. That means making sure the most specific ICD-10 codes are properly used, and clinical documentation supports those diagnoses.  And specificity will be key in the year ahead, according to Stanley Nachimson, Principal of Nachimson Advisors.


Nachimson explains:

  • Healthcare payers are going to stop letting unspecified codes slide at some time.
  • This will prepare healthcare payers for audits and health plan queries.
  • Quality measures won’t be effective unless diagnoses accurately reflect the case mix.

Also, ICD-10 proponents promised that the more specific diagnoses and codes would be used to benefit population health. Nachimson recommends that a medical practice “should invest in a robust electronic medical record (EMR) and/or practice management system (PMS) that can offer assistance in mining data.” ICD-10 implementation was just one of many changes in store for U.S. healthcare.  Medical practices need to develop robust ICD-10 coding practices to keep up with the changes.

Key Lessons from ICD-10 transitions at large hospitals

HEALTHCARE IT NEWSOCT states that for the most part, the largest U.S. healthcare providers have been very organized and prepared for ICD-10 implementation. The key lessons learned so far include:

  • Embrace technology
  • Hire enough help
  • Practice makes better medical claims – training and online tools

Implications for the “Little Guys”…. And a Solution

So what does all this mean for the many small medical practices that are out there? Do they have the same issues to deal with?  Absolutely! Codes are codes – no matter what scale you talk about. Whether you have 20 diagnosis or 2000 / day, it all seems to come down to one central theme – TRAINING

Digital-healthProTrain offers a very easy solution in its Preparing for ICD-10 Transition Course. This is a 265 Hours / 12 Months Access/ Self-Paced online course. A Course Overview includes:

Effective October 2015, the coding system officially transitioned from ICD-9 to ICD-10-CM/PCS.  The structure of the new code sets is radically different from ICD-9.  ICD-10 implementation will impact virtually all processes, technology and people within a health care enterprise.  Be ready for the transition to the ICD-10-CM with this ICD 10 Transition course.  This course will provide an introduction to ICD-10-CM coding and help you translate your knowledge of ICD-9-CM coding to the new code set. Through the use of expert developed learning modules, in-course activities, and case studies, you will learn everything you need to know to make the transition to ICD 10.

Students taking this course will be able to:

  • Describe the purpose of coding.
  • Describe the organization and structure of the ICD-10-CM.
  • Describe the conventions used in ICD-10-CM.
  • Identify the ICD-10-CM Official Guidelines for Coding and Reporting that impact the steps a coder follows when selecting diagnostic codes.
  • Explain the purpose of the ICD-10-CM Official Guidelines for Coding and Reporting.
  • Interpret instructional notes and conventions used in the ICD-10-CM codebook for Chapters 1 through 5.
  • Define the coding conventions and Official Coding Guidelines for chapters 6 – 9 of the ICD-10-CM.
  • Apply chapter-specific guidelines correctly for chapters 10 – 14 of the ICD-10-CM coding manual.
  • Apply chapter-specific guidelines correctly when coding from chapters 15, 16, and 17 of the ICD-10-CM.
  • Apply chapter-specific guidelines correctly when coding from Chapters 18 to 21 of the ICD-10-CM.
  • Explain the purpose of ICD-10-PCS and how it is used.
  • Identify the medical and surgical codes used in the ICD-10-PCS.
  • Identify the coding requirements for Obstetric procedures.
  • Identify the character meanings and root operations used for the ICD-10-PCS Placement Section.
  • Identify the approach, device, and qualifiers used in the ICD-10-PCS Administration Section.
  • Identify the approach, function, and qualifiers used for the ICD-10-PCS Measurement and Monitoring Section.
  • Identify the duration, function, and qualifiers used in the Extracorporeal Assistance and Performance section and the Extracorporeal Therapies section of the ICD-10-PCS.
  • Identify the approach, devices, and qualifiers used in the Osteopathic, Other Procedures, and Chiropractic Sections of ICD-10-PCS.
  • Code procedures from the Imaging, Nuclear Medicine, and Radiation Oncology sections of ICD-10-PCS.
  • Code procedures found in the ICD-10-PCS Physical Rehabilitation and Diagnostic Audiology section.
  • Code procedures from the Mental Health and Substance Abuse Treatment section of the ICD-10-PCS.

Learn more about ProTrain’s ICD-10 Coding course.