Are You Ready for ICD-10


What does ICD-10 mean for your organization and you?

There are a greater number of ICD-10 codes compared to ICD-9. The number of ICD-9 diagnosis codes expands from 14,000 to 68,000. The ICD-9 procedure codes increase from 4,000 to 87,000. As a result the implementation of ICD-10 requires significant changes to the clinical and administrative systems that capture and report diagnosis codes. There are structural differences between ICD-9 and ICD-10 that will make converting to the updated code set complex. The change in the character length from ICD-9 to ICD-10 requires system upgrades to expand data fields for the longer codes.

What if my company isn't ready?

Expect that not everyone will be ready by the implementation date in October 2014. Home health agencies may need to set aside cash reserves and get a line of credit. And also be prepared for the likelihood of having to use both ICD-9 and ICD-10 codes for a period of time. Fortunately, the staff at Excella has been fully trained in ICD-10 and is already providing dual coding for many agencies. Rely on Excella to help ease your agencies transition to ICD-10.

How will the change to ICD-10 effect the way we receive payment?

Because of the increased specificity of the ICD-10 codes, payers may modify the terms of their contracts for billing. Payers may require you to report the code with the highest specificity. They may alter their payment schedules and reimburse differently for higher vs. lesser specific codes. It'll be important for you to understand your payers payment schedules and to bill using the appropriate ICD-10 codes.

Contacting you billing services and vendors is the best action you can take to ensure that the transition to ICD-10 is smooth and that these organizations will continue to process your transactions after the compliance deadline.

How can I train my staff?

Determine who needs training, what level of training is needed, and when that training should take place. If you’re paying to train coders, you may wish to include a clause in coder contracts that says any coder who finds employment elsewhere within a set period of time following training will have to pay back training costs. ICD-10 coders are expected to become very hot commodities in the marketplace. While your staff is being trained, consider using Excella as your ICD10 support so you never miss a payment.

What recent changes has CMS instituted that you may not be aware of and what will these changes and future non-compliance issues cost your business?

Did you know: Experts state that 75%-85% of all agencies are unaware of CMS changes and regulations and do not have the necessary compliance rules built into their practice to protect them from wrongful submission claims. Being Medicare compliant and remaining compliant is more difficult than ever.

The following are a few facts and questions to consider;

Fact: CMS finalized Home Health sanction regulations in 2012. The effective dates for these sanctions will take effect in 2013 for non-monetary sanctions and 2014 for monetary sanctions. According to CMS, the sanctions are intended to establish alternative penalties to termination that ensure prompt compliance.

Are your current systems prepared to keep you compliant and avoid costly penalties?

Fact: Each time a diagnosis code is assigned to a clinical record and attached to that patient claim, an audit can be triggered.

Is your coding department aggressively working to protect you?

Did you know: Recently CMS issued Change Request 8136 that requires new data for PPS claims, these are new Q codes. This new requirement to report Q codes and modifiers could cause claim denials and rejections for your agency. These codes can also interrupt productivity if your agency does not have a process in place by July 1, 2013 for documenting these services.

Fact: Industry leaders predict CMS auditors will use these new codes to target duplicate services for patients.

How prepared is your team to meet these changes?

Did you know: Recently the NHIC Corp Medical Review Department reviewed selected home health claims submitted between July 1 and December 31, 2012. These reviews found consistently high error rates that resulted in 52% of the claims being denied. The top denial reason was 55H3-A; skilled observation was not reasonable and necessary. Per CMS, "Nursing services for observation are covered when the patient’s condition is changeable. Once the condition stabilizes, the nursing services are no longer necessary.” The second highest denial reason stated by CMS was lack of doctor certification. According to CMS, "The face to face encounter must be documented by the certifying physician.” The third most common denial was due to documentation not supporting the homebound status. "Reason code 55H2B is appended to the claim when documentation does not support the patient is homebound.” And finally, the fourth most common reason for claim denial was "physician orders not signed timely”.

Fact: When an end of episode claim is submitted, Palmetto may place the claims into ADR status and you will be required to submit additional documentation in order for a determination to be made on the claim either being paid or denied.

What systems do you have in place to protect you from wrongful claims that will result in ADR’s?

Did you know: Unbelievable Edits are the first predictors of fraud and can alert Z-PICS of agencies that should be audited. Auditors may monitor agencies for years, gathering data, analyzing patterns, and reviewing payments until the profile is complete.

Fact: This data and pre-probe edits allow Z-PICS to have plenty of time to monitor agency behaviors so when they send a letter, they have already completed their initial audit and have arrived at a solid conclusion.

Who is monitoring your data? How confident are you?

If your current systems are presenting you with problems and/or challenges, perhaps it’s time to try Excella back office support and experience the critical difference that will help keep your business viable and audit ready. We are here to help your business run smart and stay compliant. Let us know how we can help.