ICD-10: The Medical Y2K

Remember Y2K? Everyone stockpiled water and food. We were expecting an apocalyptic scenario with every computerized technology failing in epic destruction.

On January 1st, 2000, the world was ultimately unchanged. Is October 1st, 2015 the next Y2K? Payer policies have not changed. If you weren’t paid for a service coupled with the appropriate ICD-10 it will not be paid with the corresponding ICD-10.

Are all the payers going to be ready? Nope. Truth is we won’t know about all payers until October 2nd or 3rd, 2015. We usually get denials 24-48 hours post claim submission.

Medicaid and Worker’s Comp Problems:

California State Medicaid Agency will NOT be ready.

Physicians will have to use ICD-10 and Medi-Cal will have to convert it back to ICD-10. This will result in delayed payments.

Illinois and Florida Medicaid ARE ready.

California, Illinois and Florida state Workers Compensation systems claim they ARE ready but they do NOT have to comply legally (we don’t know how this affected their definition of compliance and won’t know until after October 1st, 2015).

Office Visits vs. Procedures

Office visits will be paid regardless of diagnoses as long as there is an ICD-10 code attached. Only procedures and diagnostic testing will likely be denied for an ICD-10 that doesn’t support medical necessity.

The one year grace period means that your claim will process with an unspecified ICD-10 code. It is not a grace period that allows continued use of ICD-10 codes. Therefore, we need to use this year to work towards very specific diagnosing as payers warn unspecified won’t always work after the first year.

What is ML Medical Billing Doing?

Now:

  • We have provided crosswalks to you for identification of ICD-10 codes for your practice. Where only one code replaces the ICD-10, we can choose that code. When multiple codes replace a code, we can select the most generic code but it may be denied. The purpose of ICD-10 is to encourage providers who are seeing the patient to select the most correlative code possible for the diagnosis associated with the procedure.
  • We are working on the conversion of superbills to ICD-10, though our best recommendation is to have cheat sheets in office for the correct selection of best codes for every visit. We will not be able to fit all ICD-10 explosion codes onto your current one-page superbills.

An even better consideration is to get onto an EMR/EHR that will assist you and your staff with proper ICD-10 code selection for cleaner billing and faster payments from payers.

After October 1st:

  • We will be reviewing denials daily for feedback before the next batch of claims go out.
  • ML Medical Billing will be on the lookout for the following denials related to the following Claim Adjustment Reason Codes (CARC) which are likely to be used for ICD-10 denial:
    • CO16 – claim lacks information
    • CO15 – authorization number is missing/invalid
    • CO165 – no referral
    • CO197 – pre-cert/authorization/notification absent
    • CO198 – pre-cert/authorization exceeded
    • CO11 – inconsistent with the procedure

The current industry prediction is that ICD-10 denials will be vague in nature. The challenge will be identifying whether the root cause of the denials are ICD-10 related. Don’t worry, though, we’re on it!

Still worried about ICD-10? If you are NOT on Kareo, now is a great time to transition. All clients on Kareo will have minimal interruption in claims processing from the billing side as their claims converting tool is seamless and time saving for us. Not only will Kareo prompt us to convert an ICD-10 you give us to a corresponding ICD-10 code but it will alert us to a failure to meet medical necessity for expensive procedures and diagnostic tests.

This will GREATLY reduce your denials!