ICD-10 Trends: Identified
Tiya Mitchell, Greenway Revenue Services
Program Manager
Nick Hickman, Greenway Revenue Services
Industry Consultant 1
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Introduction
We are almost two months into the ICD-10 transition –
and well, not too much has happened. The calm before
the storm?
In today’s discussion, we’ll cover post ICD-10
implementation trends :
• Payer changes that may affect your practice
• Government and Legislative updates
• Financial trends from Greenway Revenue Services
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Poll Question
• Which ICD-10 trends are affecting you the most?
o
o
o
o
o
LCD/medical necessity issues
Decrease in payments
Payer processing issues
It’s too early to tell
Other
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PAYER CHANGES/
UPDATES
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Prior to 10/01/2015
• CMS and AMA announce flexibility ruling
– Claims will not be denied provided diagnosis codes are in
the “same family”
– LCD/NCD policies have not changed; level of specificity
defined remains the same
– Claims are required to contain ICD-10 codes
• Advance payments are authorized by CMS if a claim
is non-processable by Medicare due to ICD-10
complications; does not apply to provider errors.
• No action was taken by Congress or CMS to delay or
stop the ICD-10 implementation
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Poll Question
• Who is your largest payer?
o
o
o
o
o
Aetna
BCBS
Cigna
Humana
Medicare/Medicaid
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Payer Status - Commercial
• Major Commercial Insurers are generally ready
• A few bumps along the road
– CA Blue Shield – Initial ICD-10 claims processing revealed
missing subset of codes; this has been resolved
– BCBS of Kansas City – Claims with DOS after 10/1 have
been denied erroneously due to an incorrect systems error
• Smaller insurers may be behind the gauntlet
– Inter-Americas Insurance Corporation – Not ICD-10 ready;
no ETA when this payer will be compliant.
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Payer Status - Commercial
• Varying interpretations/alignments with CMS
flexibility rules
– Aetna – “Aetna will require providers to use ICD-10 coding for all
transactions with an October 1, 2015 date of service and forward…” –
Matt Clyburn, Spokesman
– Humana - "Humana is continuing to follow CMS guidance on the
transition.” – Kate Marx, Spokeswoman
– Anthem - "Anthem will adhere to the CMS/AMA Medicare Part B
announcement released on July 6, 2015, specifically, Anthem will not
reject Medicare Part B Fee-For-Service claims that are coded with an
ICD-10 within the correct family even if the correct level of specificity
was not used.“ – Gene Rodriguez, Spokesman
– Cigna – “A code will be invalid if it has not been coded to the full
number of characters required…” – Mark Slitt, Spokesman
www.Healthcarepayernews.com
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Payer Status – Casualty/Worker’s Compensation
• Worker’s compensation payers are not HIPAA
covered entities.
– Readiness is predicted to be Medium to High
– May or may not accept ICD-10 codes
– WEDI – Lists more than 20 states that have decided to
adhere to CMS mandate
– Preliminary statistics show 65% of providers are coding in
ICD-10 for Property and Casualty claims
www.icd10monitor.com
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Payer Status - Government
• Medicaid – Four states announced they will not
implement ICD-10 directly; approval granted by CMS
– LA, CA, MD, MT
– ICD-10 codes will be converted back to ICD-9
– Payer discretion at play
• Medicare – ICD-10 transition moving forward
– 4.6 million claims submitted per day (10/1-10/27)
– 2% of total claims submitted were rejected due to
incomplete/invalid information
– 0.09% of total claims submitted rejected due to invalid
ICD-10 codes
www.CMS.gov
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Payer Status - Government
• Although there is progress, obstacles lay ahead
– Indiana Medicare – claims with G0105 code are being
denied due to systems not being upgraded to ICD-10. The
update will occur in January 2016, per representative.
– Colorado Medicaid – claims with diagnosis code R10.2 are
being denied incorrectly due to patient’s sex. The payer
has been notified and is working to resolve this issue.
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Clearinghouse Update
• No significant increase in number of rejections
– Since 10/01, rejection rates have been at or below
baseline
• ICD-10 claims volume is slowly increasing towards
100%
– As of 10/23, 75% of claims sent were ICD-10
www.ICD10monitor.com
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Medical Necessity
• Several MACs have identified medical necessity
issues since ICD-10 implementation
– WPS – routine diagnosis code denials
– First Coast Service Options – mammography claims denials
– Palmetto GBA – vaccine services denials
• Issues are being rectified as identified, usually
• LCDs and NCDs are being updated by MACs
• Most resolutions do not require provider action
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What is an LCD?
• Coverage decision made at the discretion of a
Medicare Administrative Contractor (MAC)
• Provides guidance to public and medical community
within a geographic area
• Educational tool that can assist you in submitting
correct claims for payment
– Outlines coverage criteria
– Defines medical necessity
– Describes covered and/or non-covered services when
diagnosis codes are integral to proving medical necessity
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Using an LCD
• An LCD should be used to determine reimbursement
coverage for a specific procedure(s)
• Example: Ophthalmic injection for patients with Wet
Age-Related Macular Degeneration (Wet AMD)
CPT/HCPCS Codes:
• J2778 - Ranibizumab
Diagnoses Supporting Medical
Necessity
• H35.81 – Retinal Edema
-And one of the following• H34.811 - CRVO, Right Eye
• H34.812 – CRVO, Left Eye
• H34.813 – CRVO, Bilateral
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LCDs – Best Practices
• Review all medical necessity rejections for any topics
identified by MACs
• Ensure that your organization is not suffering from
pro-actively identified issues
• Communicate issues that are related to medical
necessity to the payer to ensure resolution
• Monitor medical necessity issue trends
• Review the MAC website often to stay ahead of
denials
www.icd10monitor.com
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GOVERNMENT UPDATES
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Change is continuous
• Changes are to be expected
– Trial and error – testing can’t anticipate all issues
• “Unspecified” may be a good choice after all
– Medical evidence may not be available without further
unwarranted testing
– Should not be used because of incomplete medical record
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ICD-10 CM: Hidden Changes for 2016
• ICD-10 endorsed by Forty-third World Health
Assembly in 1990
• ICD-10 is currently being revised
–
–
–
–
–
–
Section 1.10 – sequela description added
Section 1.C.5.c – deleted wording
Multiple sections – rewording of paragraphs
Section 1.C.20.d – additional wording added
Section 1.C.21.16 – exclusion added
Section II.E – guideline deleted effective 10/1/2014
www.Icd10monitor.com
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ICD: Moving Forward
• ICD-11 release date set for 2018
– 4743 proposals to change the foundation of ICD
• 65% content enhancement
• 21% complex hierarchical changes
• 14% additions or deletions
• ICD-11 has many new elements
–
–
–
–
6 new chapters
New concepts
New coding scheme
New Terminology
www.who.int
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FINANCIAL TRENDS
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GRS from 10/1/2015-11/5/2015
ICD-10 Claims Submitted - 1 Month
•
96,747 claims submitted
– 43,512 have been paid
– 4,905 have been denied
– 1,304 have been rejected
120,000
Claims Submitted,
96,747
100,000
1,304
4,905
80,000
43,512
60,000
40,000
47,026
20,000
*This number represents the SuccessEHS platform only
0
Claims Submitted
Unresolved Claims
Paid Claims
Denied Claims
Rejected Claims
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Poll Question
• Which of the following closely represents your
specialty?
o
o
o
o
o
CHC/FQHC/RHC/Public Health/Student Health
Podiatry
Family Medicine/Internal Medicine/Pediatrics
HIV/AIDS
Other
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Rejections by Specialty
ICD-10 Rejections by Specialty
62
93 66
42 25 10 7 5
158
CHC/FQHC/RHC
Podiatry
222
Multi-Specialty
Family Medicine
Pediatrics
714
2536
Internal Medicine
Student Health
HIV/AIDS
Public Health
Billing Company
1265
Pain Management
Physical Therapy
Neurology
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Top ICD-10 denials from Clearinghouse
• Diagnosis Code: Invalid; payer no longer accepts ICD-9
codes for date(s) of service submitted. Please resubmit
using ICD-10 codes.
• Diagnosis Code: Invalid; must be a valid ICD-10 CM
diagnosis code.
• Diagnosis Code: Invalid; payer does not accept ICD-10
codes for date(s) of service submitted. Please resubmit
using ICD-9 codes.
• Diagnosis Code: Invalid; diagnosis code must be most
specific
• Diagnosis Code: Invalid; Claim cannot contain a mixture
of ICD-9 and ICD-10 codes
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Top Denials for Post 10/1 DOS
Top 25 Denials
First Filed in Oct: ICD-10 Claims
497
614
606
510
493
495 441
NOTE- CLAIM CROSSED OVER FROM PRIMARY INS
MAY APPEAL WITHIN 120 DAYS OF DATE RECEIVED
657
672
CONSULT CONTRACT FOR RESTRICT/BILL/PMT INFO
6903
683
PRIOR PAYER ADJUDICATION PYMTS/ADJ
934
1002
SERV INCLUDED IN PMT/ALLOW FOR ANOT SERV
PAYMENT ADJUSTED BASED ON THE ELECTRONIC
1017
PAYMENT ADJUSTED BASED ON THE PHYSICIAN
1366
4855
CHG EXCEEDS FEE SCHD/MAX ALLOW
SEQUESTRATION-REDUCT FED SPDNG
1523
SERV/TEST BUNDLED COMP OF SAME PROC
OVERPAID BY PATIENT
1621
CLAIM/SERVICE LACKS INFORMATION.
4309
1882
NON-COVERED CHARGE(S).
PAYMENT BASED ON AUTHORIZED AMT
2052
FORWARDED TO THE PT'S SUPPLEMENTAL INSURER
2627
2155
2347
2502
CONSULT PLAN DOCS FOR SVC RESTRICTIONS
PROV TYPE/SPEC MAY NOT BILL SVC
YOU MAY NOT APPEAL THIS DECISION
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Avoiding Top Denials
• ICD-10 codes are not effective on dates of service
prior to 10/01/2015
• Ensure that diagnosis codes used represent patient’s
condition accurately
• ICD-9 codes are not effective for dates of service
after 10/01/2015
• Diagnosis codes must be submitted with the highest
level of specificity
• ICD-9 and ICD-10 codes cannot be submitted on the
same claim
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Top Claim Submission Error from Local MAC
• Cahaba GBA has reported the following claim
submission errors for the last month.
– Procedure and Modifier inconsistent
• Ensure that procedure and modifier are coded
correctly.
• Modifiers are still required, even with ICD laterality
– If laterality is stated in diagnosis code, and procedure
performed on same side; modifier should match
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Best Practices
• Monitor remits for payment amounts
– Are these amounts the same as pre ICD-10
– Are you seeing an increase in denials?
• Monitor Key Performance Indicators (KPIs)
– Front end rejection rates
– Average days from submission to payment for claims
– Dollar amounts submitted vs. amounts denied
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Greenway Revenue Services Benefits
• Expertise and existing relationships with key
clearinghouse and payers
• Dedicated client team with specialty specific
expertise
• On staff certified ICD-10 coders
• Bilingual patient billing call center
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In Conclusion
•
•
•
•
•
Major commercial insurers are generally ready
Reimbursement policies vary by payer
Medical necessity continues to be an issue
Change is continuous and expected
Monitor payer websites for common rejections and
denials
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Questions?
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