Be alert with ICD-10

The sky didn’t fall, but make adjustments now to stay ahead of the curve.

Now that the dust has settled after the October 1, 2015, implementation date for ICD-10, we are beginning to see what some of the problems and misconceptions regarding ICD-10 are really about. For example: The concerns about DCs not being paid due to ICD-10 were largely overstated and those in the billing business have yet to see such cases reported to date.

In fact, there was never even a slowdown in the processing of clean claims by insurance companies. This shouldn’t come as a surprise, as the Centers for Medicare and Medicaid Services (CMS) stated they would not strictly enforce the specificity of ICD-10 coding for the first 12 months. This is also evident in the private third-party payer side, too where NOS (not otherwise specified) codes are being accepted even though there are more specific codes available.

But two main problems have arisen since October 1 that must be addressed by practitioners in order to stay ahead of the curve.

Differing interpretations

The biggest issue so far with ICD-10 has been with people over-generalizing the codes. Yes, the codes do come from a single entity, but they are being accepted by groups with different opinions about what they mean and how they are used.

For example: One national office for a large insurance carrier told groups they thought A-D-S (seventh character encounter extensions) should be used as follows:

A: Active care

D: Wellness care

S: Late effect

This created a lot of confusion—and rightly so. But the Blue Cross Blue Shield Association (BCBSA) is a national federation of 36 independently owned companies that do not run in lockstep with one another and have differing policies on many things, including which ICD-10 codes will be accepted for reimbursement. This is no different from the policies they offer where some BCBS policies pay for adjustments only and some policies pay for much more.

Furthermore, some BCBS carriers have posted (and accepted) the seventh character encounter extension of D for active care, while others have not. In this respect, ICD-10 is not unlike ICD-9 in that some of the codes are regionalized (just as some ICD-9 headache codes were accepted in some states but not in others), meaning the best way to know what codes should be used is to find out from your insurance carrier.

Something to prove

Another issue that is arising with ICD-10 is the documentation requirement to support the codes billed. Following ICD-10 implementation, we’ve seen documentation requests for services billed that ultimately had the reimbursement denied because the diagnosis code reported was not adequately proven in the notes. In one particular case, during a regular medical necessity review, a Medicare carrier denied services because “PART” was not adequately documented and the claim was denied. Following an on-the-record review, we were able to show where each component of PART was located in the notes and tied to the proper diagnosis using the exact wording from ICD-10, and the claim was paid.

This process is in line with the comments from CMS that stated they won’t deny claims because a less-specific code was used. But they did try to deny this claim due to lack of support for the diagnosis code reported. Note the importance of this process by Medicare carriers, especially since the last release of figures from Palmetto GBA Rail Road Medicare reveal a post-payment denial rate of 60 percent for chiropractic claims.

With the soft launch of ICD-10 in effect until October 2016, the fact a claim was paid with the current code set you’re using may not mean much once documentation is requested.

In the near future, DCs will look back at October 2015 the same way people look back at the claims of how the Y2K rollover would be the end of the world. But hindsight is 20/20, and now it’s easy to look back and laugh at the people who were building bunkers because they thought computers would melt down.

The same is true with ICD-10 and the October 1, 2015, implementation date with one exception: January 1, 2000, was just business as usual because there were no real issues with the date change. With ICD-10, however, even though payments have continued and the sky isn’t falling, it is anything but business as usual. Going forward, you still need to pay close attention to how ICD-10 is used by your local carriers for reimbursement and what it takes to document the specific codes.

 

John Davila, DC, established and operated three practices in South Carolina for 13 years. Since 2000, he has been training doctors and their staff about federal and state insurance compliance. He also has consulted for major insurance carriers. He is also the founder of Custom ChiroSolutions, and can be contacted through customchirosolutions.com.