Avoiding ASC Claims Denials in the ICD-10 Age: 8 Key Concepts

Ambulatory surgery center reimbursement is based on CPT codes, but this does not mean ASC leaders are exempt from ICD-10 preparation. Four billing and coding experts explain how ICD-10 could affect ASCs and how to minimize the risk of related claims denials.

How can ICD-10 impact ASCs?

Keith TobinKeith O. Tobin, vice president of sales and marketing with Medorizon, says the top ICD-10 risk areas for ASCs include:

•    Appropriate physician diagnosis coding
•    Supporting documentation in operative notes
•    Use of dual coding for commercial payers and Workers' Compensation
•    Practice management software and EHR, if applicable, readiness
•    Billing for implants

If not addressed, each of these risk areas has the potential to significantly slow ASC A/R days and diminish productivity levels.

What can ASC leaders do to minimize claims denials?

1. Get back to the basics. Before leaping to hire extra help or pouring funds into preparation, take a moment to assess how the center stands with proper payment and denials today. Are you getting paid properly? If not, what needs to be done?

"Now is really a good time to have your shop running on all cylinders," says Brian Bourke, a healthcare consulting manager at Honkamp Krueger and Company and member of the National CPA Health Care Advisors Association. "If there is a problem now, find it and fix it." WorkBrian Bourke towards healthy A/R days and create a baseline. After implementation, refer to that baseline. Has reimbursement or number of denials changed? Strive to maintain the levels prior to ICD-10.  

2. Identify top ICD-9 codes. ICD-10 contains a vast sea of codes, many of which critics and humorists alike have been quick to point out may never find their way into practical use (i.e. unspecified balloon accident). Rather than focusing on sheer numbers, identify the codes that matter to your organization.

Betty Gomez"Look at the current usage of ICD-9 codes and how specific physicians are getting right now," says Betty Gomez, head of regulatory strategy with ZirMed. "Peg the most common codes and translate them to ICD-10 to see the level of specificity that will be needed." If there are problem areas in ICD-9, put in place plans to mitigate risk in ICD-10; tackle issues head on rather than allowing them to become magnified in the new code set.  
3. Train and assess coders. ICD-10 represents a significant shift in work volume and complexity for coders. "Offer training and resources to enhance the opportunity to code accurately," says Mr. Tobin. If an ASC outsources coding, reach out to the service provider and ask what is being done to educate coders on the upcoming switch.

As Oct. 1 draws nearer, check to see what impact training has had. "Assess coders periodically. This is like learning a brand new language," says Ms. Gomez. "You don't learn it over night."
4. Reach out to trading partners. Payers, vendors and clearinghouses all have a stake in how successful providers will be in making the transition. "Understand how ICD-10 will change the whole landscape of healthcare, not just the types of codes being used," says Ms. Gomez. Identify key contacts for each trading partner and keep the line of communication open. How far along are the trading partners in their preparation? Do they have contingency plans in place for issues after the switch?

5. Test as much as possible. Medicare Audit Contractor recently held an ICD-10 front-end testing week and the Centers for Medicare and Medicaid Services announced plans for end-to-end testing during the summer. End-to-end testing has been identified as a lynch pin in the ICD-10 transition. "You can make as many phone calls as you want, but nothing is going to ensure you have the right processes in place until you submit claims," says Mr. Bourke. Identify the commercial payers, vendors and clearinghouses prepared to accept test claims. Track denials during the testing period and identify the cause.

6. Communicate. Internal communication is equally as important as reaching out to external partners. "You already need to be talking to the surgeons that use the facility," says Angie Hicks, director Angie Hicksof product management at SourceMedical Solutions. "Everyone needs to be on the same timeline."

Coder queries will increase after ICD-10 comes into play. "Study this ahead of time and put a good process in place," says Ms. Gomez. Coders will be better prepared and communication will be streamlined.

7. Build an ICD-10 team. ASC staff resources are limited; everyone is committed to a busy schedule. Find the people that shine in ICD-10 preparation and gather them together to serve as team. "You need the people that have the resources to diagnose a problem and intervene," says Mr. Bourke.

Select staff members from the business and clinical side. Though these two arenas may have once operated in isolation from one another, ICD-10 will affect both. "Put together a war room of experts who know how to troubleshoot any issues that may arise," says Ms. Gomez.  

8. Put in place a contingency plan. Thorough testing, communication and organizational planning will mitigate ICD-10 risk, but ASC productivity and revenue could still be impacted. In addition to planning for the initial switch, strategize beyond Oct. 1.

Required specificity may vary from payer to payer. "If your software application provides   denial reports, monitor these closely and look for trends with specific payers," says Ms. Hicks. Reach out to your contact with each payer. Regularly check in with vendors and clearinghouses. Take a holistic approach, says Ms. Hicks.

Check to ensure your practice management system allows for dual coding. ICD-10 is only required for HIPAA-covered entities. PM systems will need to code in ICD-9 and ICD-10 to ensure claims can be processed for both HIPAA and non-HIPPA covered entities, says Ms. Hicks.

Also understand that coder productivity will be under duress. Work with physicians to ensure specific, accurate documentation. Expedite denials as quickly as possible. Estimate potential losses due to denied claims and take into account now that revenue could be affected.

The other side of the coin
The ICD-10 conversation has been dominated by strategy, denial and even fear, but there is a light at the end of the tunnel. ICD-10 promises benefits, not only burden. "Look at how dramatically it could improve physician documentation, coding and accuracy of patient records," says Ms. Gomez. "Take this opportunity to improve your processes."

More Articles on ICD-10:
ICD-10 Preparation for Small & Medium Physician Practices: 7 Actions to Take Now
CMS Stands Fast on ICD-10 Compliance Deadline
35 Statistics on Provider Expectations of Changes After ICD-10 Implementation

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