The International Classification of Diseases (ICD) classifies diseases, symptoms, injuries and more. ICD codes are assigned to a category and identified by a code of six characters or less. ICD-9 was published in 1977, and it is widely used between healthcare providers and payers. The classifications in ICD-9 are at this point fairly old and inadequate to track all the changes and improvements that have occurred in the healthcare space; the answer to that is ICD-10, which is going to become the new required standard by October 2014.
To implement ICD-10 industry wide, healthcare providers, payers, clearinghouses need to upgrade their systems to become compliant with ICD-10 codes. The problem is that there is no such thing as a 1-to-1 mapping between ICD-9 and ICD-10; ICD-10 is not just a superset of ICD-9; it’s a totally different code set. There are cases in which an ICD-9 code has a precise match in ICD-10, but in most cases that’s not true; in some cases there are only approximate matches available; in some others multiple possible matches exist; in some others only combinations of multiple ICD-10 codes can replace the information conveyed in a single ICD-9 code.
With the ICD-9 to ICD-10 medical coding industry evolving and changing at an unprecedented rate, the focus has shifted from simple to complex and complete documentation – be it on the clinical or process side.
Many consider documentation a pain and assume their Electronic Medical Record (EMR) will take care of it, fail to understand the importance of it. It may not be required immediately, but it can be safely presumed that it would very critically needed at very near future. Lets highlight some instances where proper documentation is not only an option but also a must-have.
Accurate medical billing and coding:
Documentation is the key to accurate Billing and Coding. Many entities follow the simple rule – ‘If it is not documented, it cannot be Coded or Billed’. This policy is followed not only to promote ‘Best Practices’ in Billing, but also to avoid later complications during Audits. Any omission of details while documenting can lead to under payments and/or even denials. Many Providers realize the extent of revenue loss incurred by them due to poor documentation, only when they go through an audit of their past claims. Moreover, since ICD-10 being much more detailed in its Code-sets, demands clinical documentation to be precise in order to get accurate payments.
Process improvement and re-engineering are the key to evolve with the changing times for any process, including medical billing and coding. Failure to improve or re-engineer processes in accordance to new guidelines and rules, results in denials and underpayments which ultimately lead to the demise of the entity. There have been instances where Healthcare institutions declared bankruptcy just because of inefficient processes, improper documentation or an inability to change with the times.
Appeal for denied claims:
Appeals work at two levels, with the Insurance payer as well as when being Audited by Recovery Audit Contractors (RAC), Medicaid Integrity Contracts (MIC) or Zoned Program Integrity Contractors (ZPIC). When the documentation is good, denials can be re-filed and appealed with more authority, which results in faster and higher payments. Once a track record for excellent documentation is established, the Payers accede to review requests faster.
The most frightening nightmare that a practice can have is – the insurance audit. With the advent of the Recovery Audit Contractors (RAC), Medicaid Integrity Contracts (MIC) or Zoned Program Integrity Contractors (ZPIC), every Healthcare entity is at risk of being audited and penalized. The only solution that can alleviate this problem a little is by having proper documentation. Also, the Appeals data of the past 2 years show that Healthcare professionals with complete and proper documentation had a very high success rate when they appeal the ruling made by the Auditors. It certainly pays to be methodical and careful with documentation instead of losing both past and potential future revenues to Audits.
The need for documentation in medical billing doesn’t end with this short list. Every process in medical billing and coding needs proper and complete documentation that can help in the filing of clean claims and improve reimbursements.