Skip to main content

Payers and Medical Practices in a post-ICD-10 World

November 24, 2015

Payers_and_ICD-10.jpgThe October 1st deadline for implementation of the ICD-10 changeover has passed and the world hasn’t come to an end, patients are being seen and claims are being submitted – and paid. At a recent panel led by the Medical Group Management Association (MGMA), participants representing major payers including UnitedHealthcare and Humana and clearinghouse Emdeon, agreed that so far rejection rates have been lower than expected for this early following implementation. They cautioned, however, that it’s still too early to say how successful implementation will turn out to be for many practices are still implementing the system.

Ross Lippincott of UnitedHealthcare remarked that as of October 9, his company had processed 2.3 million claims, adding that calls to provider call centers were within their normal ranges, there were no problems with pre-authorizations with only a slight upturn in rejections that was below 0.2 percent. Both he and Sid Herbert, Humana’s director of their ICD-10 implementation team, believe that their companies had done a good job preparing providers for the new coding system, pointing out that over half of the claims that had come through by October 7 used ICD-10 coding. They also added that their companies had all provided command centers to keep providers abreast of any necessary changes in policy or other information as well as answer general coding questions.

According to Robert Tennant, Health Information Policy Director for the MGMA, everything he has heard thus far indicates that claims are moving along through the system with few glitches. Had there been major issues, he believes that he and other payers would be aware of those; however, there are questions and reimbursement issues that remain to be answered. One of these concerns four state Medicaid agencies including California, Maryland, Louisiana and Montana, which don’t accept the new ICD-10 codes, adding he wondered whether granular coding would indeed produce better data and improvements in patient care.

In addition to the call centers with payers, providers can get help from the CMS directly: starting October 1, 2015, the CMS ICD-10 Coordination Center will be available to advise providers on collaboration and other matters related to implementing ICD-10. The office of the ICD-10 Ombudsman will be part of the Center to identify and resolve problems that arise in the course of implementation. Questions from providers that are submitted to the Ombudsman’s office will be reviewed and referred to the appropriate respondent.

Top 5 Signs your practice may not be ready for ICD-10!

To further help physicians and other providers, CMS mandates that Part B claims billed under a fee schedule will not be denied outright due to a “lack of specificity” so long as the correct code family is used with a valid code. In July of 2015 the CMS made clear their definition of ‘code family’: the code submitted is a complete code falling into the category of three-character codes. For example, code 110 is a valid three-character code for essential hypertension with no other codes in that category.

It should be remembered that even with this assistance and flexibility guidelines by both the CMS and AMA, there will inevitably be ICD-10-related rejected claims. Providers will need to keep up with ongoing training for all staff from initial claims filing to appealing denials.

If all this sounds confusing, especially for smaller practices with limited time and resources, it doesn’t have to be. Working with a professional medical billing services organization such as M-Scribe Technologies, LLC can alleviate much of the guesswork and potential coding errors as staff get the coding and other transition experience needed.

Contact M-Scribe for a free confidential analysis with one of our experienced consultants and learn how to save your practice money and valuable filing time while increasing revenues from improved reimbursement and fewer denials.


Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch