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News: Mitigating Revenue Disruptions from ICD-10

Norris, Stacie MBA, CPC, CCS-P

doi: 10.1097/01.EEM.0000470822.26089.3b
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Ms. Norris is a director of coding quality assurance with Zotec Partners.

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ICD-10 has far-reaching implications for emergency medicine, even more so than some other specialties, because emergency physicians provide care to every patient who walks into the ED. It was delayed in 2014 as part of the Protecting Access to Medicare Act of 2014 (the SGR temporary fix for 2014 was also in this bill), but its implementation date is fast approaching — Oct. 1. All providers and coders will have to utilize every part of ICD-10 CM, not just some sections.

Providers, of course, are concerned about ICD-10's implementation, not just how will payers it, but also how physicians and billers can mitigate possible revenue disruptions. No one can know for certain what payers will do with the increased specificity of diagnostic codes provided by ICD-10 CM, but we can make a few reasonable assumptions.

ICD-10 CM has the potential to be used as more of a payment tool for payers than ICD-9 CM. The increased specificity of ICD-10 coding, for example, could be used by payers as a tool for more claim denials or to postpone claim reimbursement to providers.

Billers should put processes in place to track and appeal claims affected by ICD-10 denials to stem potential losses and delays in revenue. Charts also can be suspended and sent back to providers for additional documentation, creating more delays. Most billing experts recommend having reserves, such as a line of credit, to cover at least three months of operating expenses in case of possible cash-flow disruptions. ICD-10 should always be included in discussions when negotiating payer contracts, and language should be incorporated whenever possible to protect the physician practice from adverse claims decisions based on ICD-10.

Payers must be educated about the special environment of the ED, such as EMTALA requirements and limitations on how specific the ED provider can be for some illnesses and injuries based on the diagnostics available. ICD-9 has six possible knee sprain codes, but ICD-10 has approximately 80. The explosion knee sprain codes is partly from specifying the exact ligament that was sprained. It is not possible to get to this diagnostic granularity in the emergency department unless an MRI is performed, and payers have to be made aware of this and that it isn't cost-effective for every patient to have an MRI for a possible knee sprain.

If your ED practice works with a revenue cycle management provider, ask if it's possible to obtain ED-specific ICD-10 resources such as quick reference documents, case-specific coding examples, and guidance documents to review before ICD-10 is implemented. Don't wait till Oct. 1 to discuss how ICD-10 may affect your ED practice.

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