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.

One of the key benefits of ICD-10-PCS is more accurate payment for procedures.  The ICD-9 code set has now been exhausted and new codes cannot be added which limits the ability to code new procedures. Treatment techniques and methods have evolved over time and not all advanced treatments can be coded using ICD-9 accurately.  In addition, new procedures are more expensive than the procedures they replace so they are not being fully reimbursed.

ICD-10-PCS can help in understanding the value of new procedures that will no longer be lumped in with the old procedures; as they often are with ICD-9.  Providers and payers can leverage the data to determine how effective such procedures are and for which populations.  This could shift when and where the procedures are performed with net benefits as a result.  For example, ineffective procedures would be done less often; effective ones would be extended to new patients.

This increased specificity of the codes will make it easier to compare reported codes with clinical documentation, check for consistency between diagnosis and procedure codes, and check for illogical combinations of diagnoses.  The use of ICD-10-CM thus may also help reduce opportunities for fraud and improve fraud detection capabilities.  Fewer gray areas in coding will make it more difficult for dishonest providers to hide behind ambiguities in code descriptions or rules.

In summary, benefits will materialize for your healthcare organization if your approach towards ICD-10 is based on collaboration and innovation and is not a pragmatic approach which focuses on just being compliant with the mandate.

One response to “ICD-10 Basics: Achieving Accurate Reimbursement

  1. Right you are! This is a joint issue whcih requires a joint resolution. Basically, payer and providers will be using a new clinical and financial language. The degree to which they master the new language together will directly impact the mateiralization of any benefits from the increeased granularity of the codes. If the partners are not speaking the same language there will not be much hope for optimizing the codes sets. There must be a real “meeting of the minds” with respect to contracted rates.

    If we consider the fact that an entire billion $ industry (denials management) was born out of the inability for payers and providers to come together on reimbursement and how to best provide care, there is not much hope for willingness to join together for ICD-10.

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