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Avoid needless ICD-10 claims denials: Act now to update access processes
Coding will become more complex
Two major areas of concern for the switch to ICD-10 are medical necessity and preauthorizations, according to Susan Hoyle, CCS, coding manager at Mission Hospitals in Asheville, NC. National coverage determinations, local coverage determinations, and insurance company coverage benefits will need updating, due to the increased specificity of ICD-10, she explains
Your patient access staff will be using ICD-10, the new procedural coding system developed by the Center for Medicare & Medicaid Services, as of October 2013. The new system will replace the ICD-9-CM procedural coding system used for hospital reporting of inpatient procedures.
"The risk for us will be having something not covered or paid for, due to lack of specificity needed for the codes that will meet the coverage and/or authorization guidelines," says Hoyle.
Tests such as CT scans or magnetic resonance imaging have local coverage determinations that define the diagnoses that are required before the test will be paid for, says Hoyle. "If one of those diagnoses is not on the claim, then it is does not meet medical necessity," she explains.
Rennae J. Glidden, RHIT, director of data services at HealthEast Care System Midway Campus in St. Paul, MN, warns, "Success with prior authorization and insurance verification will depend on accurate assignment of either ICD-10 diagnosis or procedure codes requested by the insurer."
Collaboration is key
Hoyle says that patient access' biggest challenge will be getting the codes needed to determine if a case will meet criteria for coverage or preauthorization.
"Training the patient access staff to know what additional information is needed to determine the most accurate codes will be critical," she says.
Working closely with coders and physician offices will be essential to the success of the patient access team, adds Hoyle.
Hoyle says Mission Hospitals' ICD-10 program is composed of several teams across the health system. "Each team is working to identify the impact of ICD-10 in their area," she says. Right now, the department is identifying processes, software, and personnel that will be impacted, says Hoyle. "We are evaluating additional functionality in current systems that could be used by Scheduling and Patient Access, to enable a successful transition," she says.
Marsha Kedigh, RN, MSM, director of admitting/ED registration/discharge station/insurance management at Vanderbilt University Hospital in Nashville, TN, is expecting an initial slowing of work flow in her department's pre-admissions processes. "This is due to the staff learning curve," she says.
The processes of determining the reason for admission, determining inpatient or outpatient status, as well as the scheduling process for inpatient and outpatient procedures will be affected, adds Kedigh.
Avoid claim errors
Patient access staff will be working with a new set of diagnosis codes that have increased in length by two characters and which now contain alphanumeric characters, explains Jeffrey Smith, RN, MBA, CPC, a New York City-based manager at Accenture Insight Driven Health, a management and technology consulting company.
Claim errors could result if staff members are processing any code information that appears on a bill from lab or radiology, cautions Smith. "You will need to look at the billing process. Make a determination if any codes entered upfront end up on the bill. There could be some," he says.
There are about 14,000 diagnosis codes currently, says Smith, and this number will increase to about 68,000. Medical necessity checks could become more involved, he adds. "There will be a lot more detail to sift through," says Smith. "The expectation is that the new granular diagnosis codes will be incorporated into the medical necessity. That would increase the complexity."
For more information on preparing for ICD-10, contact:
Rennae J. Glidden, RHIT, HealthEast Care System Midway Campus, St. Paul, MN. Phone: (651) 232-7085. Fax: (651) 326-8454. E-mail: firstname.lastname@example.org.
Susan Hoyle, CCS, Mission Hospitals, Asheville, NC. Phone: (828) 213-0642. Fax: (828) 213-1522. E-mail: Susan.Hoyle@msj.org.
Marsha Kedigh, RN, MSM, Vanderbilt University Hospital, Nashville. Phone: (615) 343-0892. E-mail: marsha.kedigh@Vanderbilt.edu.
Jeffrey Smith, RN, MBA, CPC, Manager, Accenture Insight Driven Health, New York City. Phone: (315) 569-3431. Email: email@example.com.