Physician practices and medical groups have been hearing about new changes in ICD-10 coding for months. More codes are ahead and the one-year grace period for specificity is set to conclude.  At MMI, I am often asked how providers can put themselves in the best possible position to avoid ICD-10 denials as the new changes are implemented in October 2016.

I think the best preparation stems from solid education and training. As described in my recent article with ICD-10 Monitor, there are specific steps to help practices prepare. The goal is to prevent medical necessity denials before they occur—rather than chase them after claims rejections or denials.

Practices in Cardiology, Pathology/Laboratory and Radiology will be most impacted by the changes. Diabetes, neoplasms and pain codes are also key areas for medical necessity concerns in ICD-10. Here is brief synopsis of training tips I provided in my article.

  1. Clinical Documentation Improvement
    The importance of CDI cannot be understated. The goal for each physician encounter note is to answer the “why” of every visit, every procedure and every test. As ICD-10 denials occur, be sure to track them and determine if denial was due to a coding error or missing documentation. When a medical necessity denial occurs, track the specific reason for the denial as well as the specialty, clinician and payer. Share this data with the entire clinical, coding and billing team within your practice or medical group.
  2. Track Unspecified Codes
    Perform an audit that examines the use of unspecified codes. Is an unspecified code clinically appropriate, or could the physician have documented greater specificity? Unspecified codes are predicted to be a key target for payer denials in 2016 as the grace period for physician practices comes to a close.
  3. Monitor and update NCDs and Local Coverage Determinations (LCDs)
    Review your NCDs and LCDs annually, especially for high-volume procedures. To find more information about NCDs for your specific region, visit….https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
  4. Enhance Workflows with Your EMR vendor
    When possible, build (or enhance) EMR templates to encourage greater specificity in clinical documentation. For example, for coding pain, specific extremity, location and laterality must be coded.
  5. Review all Pre-authorizations and Referrals
    Ensure that any orders for ancillary testing include specific ICD-10-CM codes that meet medical necessity requirements. Lack of sufficient physician documentation for ancillary testing and procedures triggers denials.
  6. Study Your Payer Policies
    Revisit payer policies for your most common diagnoses, procedures and testing once the new ICD-10 codes are in place. Incorporate education and training protocols into your office procedures so that your entire team has these changes top of mind.

A proactive approach to educating and training everyone on your team will have a positive impact on your revenue cycle—despite all the change ahead!