ICD-10 Gets Down to Specifics, and Attention to Detail Directly Affects Finances

This year, getting reimbursed is all about making sure the codes reflects the actual care given.

For ICD-10 changes this year, the devil’s in the details.

When ICD-10 was first implemented on Oct. 1, 2015, it was a nail-biting flip of the switch and then a sigh of relief when denials didn’t mount up as some feared.

This last October, providers dealt with a monumental amount of changes to the ICD-10 coding system.

This year, there’s less than 400 new codes — some noteworthy such as a classification for mild, moderate or severe in the severity of substance abuse remissions.

The larger view, said two experts interviewed, is that this October it’s all about narrowing down specificity in the clinical documentation, to make sure the coding reflects the actual care given.

When it’s done right the first time, there’s fewer queries to physicians and less lag time to getting paid.

“The idea is to minimize billing time, reimbursement time, get a clean claim and get money get faster and improve cash flow,” said Denver Wade Harless, who works for the Sacred Heart Health System, which is part of Ascension.

Harless, a regional health information management director, said getting the correct documentation in real time is becoming more important.

“For the first time in a long time, I think the impact will also be on reimbursement, but will include the reporting status and level of care hospitals are measured against for mortality and quality, which in turn will cause everyone of us to more closely monitor in real time rather than after the fact,” Harless said.

If an addendum to the code is added two days later, that’s OK. if it’s 25 days later, it immediately goes into question and holds up the claim, Harless said.

“If the codes are more specific it will make it easier to follow the flow,” Harless said. “Right now there is a gap. A lot of clinical legwork needs to be done.”

This means getting more specific information from physicians.

“My philosophy is to get the physician to write down what’s in his or her head, on paper,” Harless said. If that happens, he said, “we have it made.”

The process of clinical documentation improvement, or CDI, is easier said than done, Harless said, though the four hospitals he works with have seen some positive results from educating physicians on the process.

The coders can’t assume, for instance, that sepsis is associated with organ failure, said Victoria M. Hernandez, a senior consultant of Auditing Services for the Primeau Consulting Group, which works with hospitals such as Torrance Memorial Medical Center in California on its ICD-10 coding quality.

“Coders should not be disregarding physician documentation and deciding on their own whether or not a condition should be coded,” Hernandez said. “We have to query, the physician must document.”

With fewer queries the aim, this year, the words “with,” “in” and “due to” in ICD-10 codes will go a long way towards reaching that goal, said Hernandez.

Having the term “in” helps coders, for example, tie Alzheimer’s or dementia to alcohol, as in “dementia in alcohol,” she said.

“Now, every time we say ‘in,’ we assume the linkage, unless it’s explicitly explained it’s not related,” Hernandez said.

This linkage pertains specifically to diabetes this year. In previous years, there was no link to a complication with diabetes.

The new codes include Type 2 diabetes mellitus with ketoacidosis, Type 2 diabetes mellitus with ketoacidosis without coma and Type 2 diabetes mellitus with ketoacidosis with coma, according to Gloryanne Bryant of ICD10Monitor.com.

Bottom line: This cause and effect affects reimbursement.

“A diabetes with no complications to one with (complications), falls under a different HCC (hierarchical condition categories) category,” Hernandez said.

Some plans such as Medicare Advantage rely on the HCC system for reimbursement.

There’s also some new codes for myocardial infarction and heart failure.

“It’s more specific, it’s painting a picture of chronic and acute conditions and what services were used for the patient,” Hernandez said. “It chronicles medical necessity and what was done.”

This is especially important for elderly patients who may come in for one type of care but have an underlying chronic condition.

“I would say they do need to capture every chronic condition that the patient is currently being treated for,” Hernandez said of physicians. “If it happened, document it, it will be coded. It’s painting that whole picture. It will save coders CDI queries. Now you can really get your specificity down for tracking the whole illness burden.”

Hospitals she works with are ready, she said.

“From organizations I’ve audited, they have distributed the guidelines,” Hernandez said, “they’re pretty much giddying up for that educational part.”

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Photo courtesy of: Healthcare Finance

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