Lolita Jones, RHIA, CSS, independent coding and billing consultant, discusses five ways ICD-10 will affect “front office” processes in an ambulatory surgery center. This article is the second installation in a four-part series. Read Ms. Jones’ thoughts on six initial ICD-10 preparation steps here.
1. Physician credentialing. Ms. Jones says ICD-10 may affect the way ASCs credential physicians to perform cases at the center. “It has come to my attention that most — if not all — of the credentialing software out there has fields for codes,” she says. “Those could be diagnosis codes, which would now be in ICD-9-CM and would need to be converted or upgraded to ICD-10.” She says the fields may be used to capture the type of conditions a privileged physician might treat, and the software may use a coding format to capture the information.
She says ASCs should look at their credentialing software to determine if the fields currently contain ICD-9-CM diagnosis codes. If they do, the ASC should communicate with the vendor to discuss how the software will be upgraded for ICD-10. She expects that most vendors will have an ICD-10 plan — but says ASCs should not depend on an upgrade arriving at their door without extra effort on their part.
“We can’t assume every upgrade with a vendor would be [included] with the existing contract,” she says. “You may need to enter into a new contract, or there may be costs they want to pass on to customers.”
2. Pre-registration staff training. ICD-10 will affect the pre-surgery process in multiple ways, and ASCs must research how to best train their pre-registration staff to handle changes, Ms. Jones says. She says some staff members will need a basic level of training, while others will require an intermediate level. “If they have no involvement in coding other than perhaps entering a code they see on a document, the only thing they need to have is a basic understanding of ICD-10,” she says. This means going over what ICD-10 is, the change in format and a general overview of its effect on the ASC.
If pre-registration staff members have more involvement in coding, they may need an intermediate level of training, Ms. Jones says. These staff members may be responsible for assigning a diagnosis code based on narrative information they are given during the pre-registration process or for advanced beneficiary notice letters. “You would give them the structure of ICD-10 [like the basic training], but you would also go over the pertinent factors of ICD-10 that would apply to your ASC,” she says. For example, if you are an orthopedic-driven surgery center, your pre-registration staff should gain an understanding of the musculoskeletal chapter of ICD-10. If you run an ENT-driven ASC, your staff should have a good sense of the respiratory chapter.
3. Pre-registration process. Ms. Jones says the pre-registration process will change in several ways when ICD-10 is implemented. For example, the registration system or software in an ASC will have to update its procedure codes to ICD-10. ASCs that are able to populate the data dictionary in their registration software with diagnosis codes will need to examine whether that dictionary can be replaced with an ICD-10 file. Ms. Jones says those files will continue to be posted by the government, but a vendor or consultant might be useful to help transition the software.
4. Coverage determination. Ms. Jones says some ASCs may have previously purchased software that makes coverage determinations available online. “Instead of having to research various policies for different plans, such as Medicare or Blue Cross, they may have software where the vendor makes the information available to them electronically,” she says. If an ASC does not have electronic access to medical necessity policies, the center needs to make a staff member responsible for monitoring payor websites and documents for updates.
“For example, a payor may have a policy that says, ‘We will cover arthroscopic shoulder repair only if these diagnosis codes appear on the bill,'” she says. In that case, the staff member should monitor the payor’s website to determine which ICD-10 codes will justify an arthroscopic shoulder repair in the center. She says the information may appear in 2011, 2012 or 2013, but a staff member should check the websites every month to stay informed. She says centers should not ignore smaller payors, even if 80 percent of the ASC’s revenue is driven by four or five major payors. “You still want to be paid by those other payors on Oct. 1, 2013, and afterward,” she says.
5. Insurance verification. Ms. Jones says ASCs should use the ICD-10 implementation process to strengthen insurance verification, the process by which an ASC determines whether a procedure is covered by a particular payor. “I’ve noticed that a number of ASCs don’t have an insurance verification process on the front end,” she says. “They trust that if a case is being booked or scheduled by a doctor that everything is okay. The case is booked, the surgery is performed and coded and you end up with a denial on the back end.” She says some ASCs assume that because a procedure has been covered for years, the policy will not change — a dangerous mistake considering coverage policies can change in a day.
Lolita M. Jones, RHIA, CCS, is the author of the new book “ICD-10-CM/PCS Implementation Action Plan”. Visit her website at www.EzMedEd.com.
