The expectation of doom that came with the move to ICD-10 was nothing short of the hoopla surrounding Y2K (when people feared the world’s computers would shut down or malfunction). But October came and went and … silence. The industry adapted surprisingly well to the new codes and little has been reported on major problems for either payers or providers.
But experts say things went so smoothly because everyone was becoming acclimated to the changes. Now that Medicare and other payers are becoming comfortable with the new system, they will begin making changes and more closely scrutinizing claims. Here’s what to prepare for in the coming months.
The end of grace
To ease everyone into ICD-10, Medicare created a grace period allowing providers to be paid even when their codes weren’t as specific as they should be. In other words, as long as they were close, the claims were being paid.
But that will change come October 1, when the Centers for Medicare and Medicaid Services (CMS) will be starting post-payment audits that allow them to more closely scrutinize claims and audit those that require greater specificity. The result of this could just be more “back and forth” when things come into question, said Jim Daley, past chair of the Workgroup for Electronic Data Interchange (WEDI), based in Reston, VA, and co-chair of the WEDI ICD-10 workgroup. But if a pattern is found, it could cause big problems. To avoid major issues, you need to make sure you are capturing enough documentation to make coding as specific as possible.
“Are you always picking certain codes because they seem to be working and you are getting paid, or are you picking them because of the specifics of that encounter?” he asks. It should be the latter.
Nonspecific diagnoses, for example, may invite greater scrutiny. The error rate with that code is about 30%, according to Stuart Newsome, vice president of Alpha II LLC, based in Tallahassee, FL.
“Those are a target because it’s like saying you don’t really know what is wrong with the patient,” he said.