ICD-10 Basics: Achieving Accurate Reimbursement

By: Ann Frischkorn Chenoweth

As providers shift from using ICD-9 to ICD-10, there will be benefits in the form of more accurate payments for new procedures, fewer rejected claims, fewer improper reimbursement claims and greater efficiency in the billing and reimbursement process.

ICD-10’s improved precision in documentation of clinical care will greatly improve the likelihood of submitting accurate claims the first time around and receiving appropriate reimbursement.

The increased granularity of ICD-10 code will help reduce the number of claims being investigated or rejected due to insufficient information.  ICD-10 will solve the problems caused due to lack of detailed information contained in the diagnosis and procedure code assignment.  Fewer rejected claims will reduce the amount of rework for providers leading to an efficient reimbursement process which in turn reduce negative impacts to your revenue cycle.

CMS and OIG Announce New Compliance Programs

By: Barbara Aubry

On November 16, 2011 CMS announced new demonstration projects to help curb fraud and abuse. You may recall that in 2010 President Obama announced the goal of reducing overall payment errors by $50 billion, cutting the fee-for-service error rate by 50% and recovering $2 billion in improper Medicare and Medicaid payments.

As of January 1, 2012 CMS intends to begin demonstration projects to safeguard the Medicare trust fund by increasing the Recovery Audit Prepayment Reviews, prior authorization for specific DME and a continued focus on Part A to Part B rebilling.

ICD-10-CM/PCS MS-DRG Grouper Q&A Part 2

By: Ron Mills

“Mike” wrote Rhonda:

I saw a good article you wrote in The Journal of AHIMA … been very helpful … but the bigger question we are encountering is the continuity of reporting from ICD9 to ICD10. I am hoping you may be able to point me in the direction of any work that has been done on supporting data warehousing, reporting and information challenges when the data spans 2013 and the ICD-9 and ICD-10 code sets.

Rhonda passed it on to me and I responded:

Mike, you’ve got a good* problem on your hands. Here’s what I’ve been doing with the mixed ICD-9/ICD-10 databases I’ve been dealing with, those behind the extension of our products to handle ICD-10. I keep the database structure the same, but recode the ICD-9 codes so they don’t overlap with ICD-10. (See my “False Friends” blog for details.) I put “9$” in front of ICD-9 diagnoses and “I$” in front of ICD-9 procedures, so they can live in the same places as ICD-10 — the ICD-9 becomes an extension of ICD-10 in this system. Since there are roughly 140,000 ICD-10 codes and only about 17,000 ICD-9 codes, that is only a 12% increase in the number of codes being considered. Since code types are not ever mixed at the record level, a code type indicator in the record serves as well, but may require more complicated selection logic.

Building a Core Project Team

By: Jill Devrick

In my last post, I described the characteristics of a good project manager.  But he or she can’t do everything.  For most technology projects, I have found that the core project team usually contains the following mix:

New technology consultants: one or more representatives from the company that sold you the new technology. These individuals should know the product you are implementing upside down and backwards and be able to guide you through the project blindfolded. Ok, I’ll admit I’m overreaching here, but you should be able to count on your consultants to guide you through the implementation phases, give you good advice, and sometimes dole out some “tough love” during the project.

AMA Vows to Fight ICD-10

By: Barbara Aubry

During its semi-annual policy making sessions, the American Medical Association released its resolutions to stop the implementation of the ICD-10 CM (diagnosis) and PCS (procedure codes) implementation.  CMS responded that it does not intend to alter its ICD-10 migration go-live date of October 2013. Specifically, the AMA resolved to “vigorously work to stop the implementation of ICD-10 and reduce its unnecessary and significant burdens on the practice of medicine.” It further resolved that it will “do everything possible to let the physicians of America know the AMA is fighting…on their behalf.” And finally, it announced its intention to work with other national and state medical and informatics associations to determine an appropriate replacement for ICD-9.

What? Are they serious?

Putting the “Accountable” into Accountable Care

By: Sandeep Wadhwa

The talk about Accountable Care is turning into action with the announcement of the Pioneer ACO awardees from CMS.  In addition, the Medicare Shared Savings Program solicitation has been released with initial responses now being accepted.  As delivery systems and providers consider whether they want to respond, I’d like to suggest some key areas to consider.

ICD is a System and Systems are Upgraded

By: Rhonda Butler

Microsoft launched Windows 1.0 in 1985. Then Microsoft launched Windows 2.0 in 1987, Windows 3.0 in 1990, Windows NT in 1993, Windows 95 and Windows 98 in ’95 and ‘98, XP in 2001, Windows Vista in 2006 and Windows 7 in 2009. Microsoft is working on the next version.

The International Classification of Diseases (ICD) system is like an operating system for healthcare administration in the United States. In that sense ICD-9-CM is deeply embedded software: it works in the background, and it enables transactions critical to the functioning of the industry. ICD-9-CM is the primary system used to conduct the flow of money between healthcare providers and payers. ICD-9-CM is the primary statistical vehicle for studies monitoring the health of the population, the cost of healthcare, and the quality of healthcare. It would be difficult to exaggerate how much it is used. Like Windows, ICD-9 is everywhere.

And the ICD-9-CM system is 33 years old. It was released in 1979, six years before Windows 1.0 (in the era of MS-DOS, C:\ and dark screens with fuzzy cathode ray white type). Every year for the past 33 years, ICD-9-CM has been patched but not upgraded, meaning that new codes and their definitions were added, deleted or revised. Just bug fixes and tweaks in existing functionality. Never in its 33-year history has ICD-9-CM been upgraded in the sense of new design and new functionality. The new design, the new functionality is ICD-10. ICD-10 is the next upgrade.