Now that ICD-10 is a reality in the U.S. health care environment, providers are finding that October 1, 2015, didn’t bring with it the D-Day scenario they thought it might. But they also know ICD-10-related challenges that aren’t apparent now might manifest themselves in the coming months. Providers were certainly ready to submit claims come October 1, but are payers ready to receive them? And if not, how many claims will be denied?
ICD-10’s enhanced coding guidelines could lead to a higher incidence of denials due to coding errors. Even more likely, the new code set’s greater granularity could result in lower reimbursements if documentation doesn’t provide adequate detail to justify higher severity coding and DRGs.
Providers who are truly ready for ICD-10 have conducted end-to-end testing: they have submitted claims based on both ICD-10 documentation guidelines and native coding in ICD-10, and they have received an adjudicated claim from payers. These providers also have analyzed coding effectiveness and clinical documentation adequacy, and where they found gaps, provided coders with additional training and improved documentation. They found their risks and analyzed and addressed them.
Do you need an ICD-10 rapid response team?
Providers who haven’t been able to get to that level of preparation run the risk of significantly decreased cash flow. Such providers require a rapid response team watching for coding and documentation gaps, as well as a plan to address those gaps as they are identified. The following are four essential steps organizations must follow to build an effective ICD-10 rapid response mechanism:
- Make sure HIM and revenue cycle data are easily accessible.
- Develop a team of experts that can identify risks using data.
- Determine the thresholds at which the ICD-10 rapid response team takes action.
- Determine how the team will respond.
Rapid responses to manage denials: In the early days of ICD-10, it might be useful for organizations to review their top ICD-9 denial reason codes and the associated CCs/MCCs and monitor these daily for trends of increased denials.
Rapid responses to improve clinical documentation: Clinical documentation improvement (CDI) activities can serve as validation to providers about the education they have received.
Rapid responses to improve coder productivity: Organizations must track coder productivity, typically measured by the number of charts per day an average coder can complete. If coding isn’t going as smoothly as you’d like, give entry-level coders the training they need to code the simpler outpatient encounters, such as labs and radiology, then shift more experienced coders into more difficult inpatient coding scenarios.
In conclusion, most, if not all, provider organizations could benefit from an ICD-10 rapid response group. By continuously analyzing data and deploying resources to plug revenue gaps, providers can remediate ICD-10-related challenges.
About the author
Warren Hansen is an associate director of Provider Consulting at Optum360. Warren was one of the principal designers of the Optum ICD-10 consulting solution. His extensive and diverse health care background includes IT management, revenue operations, health information management and project management.