Come October 1, 2016, healthcare systems will see a plethora of coding changes. One such adjustment involves flexibilities. The U.S. Centers for Medicare and Medicaid Services will no longer exempt providers from Part B reimbursement denial due to limited code specificity. Learn more about what this means for healthcare systems and how they can prepare:
The original concession
As Healthcare Dive highlighted, when CMS made the switch from the ICD-9 to the ICD-10 coding system, organizations such as the American Medical Association requested the CMS grant certain flexibilities. The AMA knew the switch would prove challenging and aimed to find ways to ease the transition. The group wanted to ensure providers would not be held accountable for accidental mistakes or glitches in the system.
In response, CMS announced healthcare systems would not be denied Medicare claims reimbursement for lack of specificity alone. However, the entries only exempt healthcare systems on post-payment fee-for-service reviews - not prior authorization requests - and the ICD-10 entries must be valid and come from corresponding family of codes, according to the AMA.
That is, the claim code must come from the appropriate ICD-10 three-character category. These categories group data by clinical condition, and each code within that family offers a greater level of specificity.
CMS highlighted an example of this when it originally announced the period of flexibility. H25 indicates an age-related cataract and a family of codes. H25.031 represents an anterior subcapsular polar age-related cataract in the right eye. From October 1, 2015, to October 1, 2016, if providers accidentally entered H25.22, which represents age-related cataract, morgagnian type of the left eye, when the code H25.031 was actually appropriate, this mistake would not cause Medicare to deny claims billed under the fee-for-service Part B physician fee schedule because both codes fall under the same family.
An end to flexibilities
October 1, 2016, marks the end of this grace period. Beginning in just a few months, providers must enter the correct ICD-10 code, or Medicare has grounds to deny claims. Some healthcare systems are more than ready, as they have never taken advantage of this flexibility per their payers' specificity requirements. However, medical facilities using less granular codes must prepare for change.
It is vital to lay the groundwork for the transition months in advance. Healthcare systems should expect and account for decreases in productivity while staff adjusts to new coding practices. For example, hospitals may hire temporary personnel like travel nurses to balance clinician-to-patient ratios while permanent staff complete training.
"Medical facilities using less granular codes must prepare for change."
Coding is incredibly intricate, and errors may still occur even with training. Between the importance of accurately recording a patient's health history and the economic burden of claim denials, healthcare systems need a clinical interface terminology partner that can ensure each entry is exact.
Intelligent Medical Objects (IMO) offers everything medical systems need to stay compliant with CMS's ICD-10 coding updates. Our IMO 2.0 Enhanced Terminology Platform (ETP) for MEDITECH users offers all of IMO's technology in one place. Providers get access to the IMO 2.0 Appliance, Long-Term Terminology Management, Clinical Quality Measures Dashboard, IMO Anywhere and Map IT. With this solution, healthcare systems can link their local dictionaries with quality measure inputs, ensuring colloquial verbiage does not interfere with providers' ability to code with the greatest specificity possible.
ETP also makes the overall end-of-flexibilities transition easier, as it increases efficiency. For instance, ETP's improved dictionary maintenance helps providers avoid terminology searches of outdated concepts. Meanwhile, its mobile capabilities allow clinicians to document on the go.
With any transition comes challenges, but CMS's end to ICD-10 coding flexibilities is inevitable. Healthcare systems must prepare to ensure providers can still deliver high-quality care and to prevent this change from affecting their bottom line.
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