ICD-10 challenges for medical practices


Healthcare providers need to prepare for challenges that will affect their business operations and revenue cycles.

According to the Centers for Medicare & Medicaid Services (CMS), the following impacts need to be considered when developing ICD-10 transition plans:

Problems with authorization and referrals; claim delays or denials
As healthcare payers convert to ICD-10 coding, they may have to change criteria for prior authorizations and referrals. And the increased data found in ICD-10-CM codes could lead to significant increase in denials.

Medical practices need to communicate and coordinate with healthcare payers to determine how ICD-9 codes will be converted and how that can affect reimbursement policies and procedures.

Auditing, fraud and abuse
Expect audits to focus on clinical documentation to determine if it supports the specificity of ICD-10 codes. CMS recommends regular documentation audits after ICD-10 implementation to make sure your clinical documentation supports your ICD-10 coding.

Pay-for-performance
Value-based purchasing and other quality measures are expected to have major impacts on reimbursement revenues.

Case rates, capitation and other payment methods
There's little information on how payment models will change with ICD-10 coding. Again, communication with healthcare payers and clearinghouses will be key to identifying trends.

Accountable care organization (ACO) models
ICD-10 codes will be a key part of ACOs.

  • ICD-10 codes will be mandated as a standard.
  • ICD-10-CM will provide data for disease pattern analysis.
  • Resource allocation will be based upon ICD-10 data.

Value measurement
How medical practices will measure quality, efficiency and effectiveness will change. ICD-10 values won't be comparable to ICD-9 standards.

CMS also has tips for dealing with other considerations that can affect the business operations of medical practices:

Coding productivity

  • Assess the effect of decreased coding productivity on your practice’s accounts receivable status:

How long do you expect the decline in coding productivity to last?
What steps can you take to reduce the effect of decreased coding productivity?

  • Eliminate coding backlogs before ICD-10 implementation.
  • Prioritize medical records for coding.
  • Provide coding staff with adequate ICD-10 education and provide refresher training immediately before the compliance date to improve confidence levels and minimize productivity declines.
  • Assess medical record documentation and implement any necessary improvement strategies before the ICD-10 transition.
  • Use electronic tools to support the coding process.
  • Use outsourced coding personnel to assist during the initial period after ICD-10
implementation.
  • Identify areas of weakness by evaluating productivity across coding, billing and reporting functions; consider training refresher courses to boost skill sets or build particular clinical scenarios that are limiting productivity.

Coding accuracy

  • Assess the impact of decreased coding accuracy:

What is the anticipated effect on coding accuracy?
How long will it take coding staff to achieve a level of proficiency comparable to that with ICD-9?

  • What steps can your practice take to improve coding accuracy?
  • Assess coding knowledge and skills and provide an appropriate level of education.
  • Monitor coding accuracy closely during the initial implementation period and provide additional education as needed.
  • Identify areas of weakness by evaluating productivity across coding, billing and reporting functions; consider training refresher courses to boost skill sets or build particular clinical scenarios that are limiting productivity.

Documentation improvement
Assess the success of efforts to improve documentation to support both good patient care and accurate ICD-10 coding.

Go-live production problems

  • Develop strategies to minimize transition problems and maximize opportunities for success.
  • Identify potential problems or challenges during the transition and implement strategies aimed at reducing the potential negative effects. For example, develop a process to manage errors and resolve vendor issues as necessary.

Contingency planning
A separate contingency for each high-priority, potential failure point should be established to ensure business continuity.