When CMS finally rolled out ICD-10 last October after repeated delays, the new code set wasn't nearly as catastrophic as some had forecast. Rather than a complete meltdown of claims processing, denials were relatively few, usually due to either invalid code selections or valid diagnoses previously covered in ICD-9 that were wrongly considered to not meet medical necessity requirements under ICD-10. Now that we're several months into ICD-10, you may be breathing a sigh of relief, thinking you're over the hump. Not so fast. We're starting to see a resurgence in denials. This uptick is likely because CMS and other carriers are beginning to apply more stringent edits when adjudicating claims.

Close enough no longer good enough
If you remember, when ICD-10 was first implemented, CMS in collaboration with the American Medical Association offered a 12-month grace period. During this grace period, you could submit claims with a diagnosis that was "close enough," or at least found within the applicable family of codes, and still receive reimbursement. As long as you used a valid code, Medicare review contractors wouldn't deny physician or other claims billed under the Part B physician fee schedule through either an automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code.

While the goal of ICD-10 was to boost specificity in claims, the grace period may have instead promulgated ambiguity. CMS's grace period ends in October. Many commercial carriers are already denying more ICD-10 claims. Now's the time to address bad documentation practices, before they become bad habit. If your physicians are frequently reporting unspecified codes, find out why. If you've let your docs know that they need to be more specific, but they're still providing ambiguous documentation, show them the financial impact — delayed, denied or inadequate reimbursement.

What's causing the denials?
If you're seeing denials, you need to pinpoint the cause. The best way to resolve a problem is to identify why one exists. Start by tracking and trending the reasons for the denials. These might include:

• Payer processing issue. Review the carrier's remittance advice, or explanation of benefits, which explain the payment and any adjustment(s) made to a payment during the carrier's adjudication of claims.
• Clearinghouse. Ensure all claims batches are successfully transmitted and received. Identify the reports denied upon initial submission. Why was it denied — due to a system processing error or a code selection error?
• Provider documentation deficiency. If you notice that your codes are not specific enough, look to your physicians' documentation. Try implementing inquiry protocols, when applicable, according to both the individual organization and state policies. Unspecified code applications should not be the standard.
• Facility coding error. Look for true coding errors. Is the code invalid, missing an additional digit, placeholder or 7th character? Was the code selection incorrect, or should you have reported a more specific code? If you spot a pattern of errors, address it with your coding staff.

BE SPECIFIC Your providers may be used to providing unspecific documentation, but moving forward you'll receive more denials if they don't detail their diagnoses.

DETAIL YOUR DIAGNOSIS
ICD-10-CM's Heightened Level of Specificity

The higher level of detail in ICD-10 codes lets you more precisely code the diagnosis. Take degenerative disc disease (DDD), for example. In ICD-9, a diagnosis of DDD with no mention of the anatomical site was coded as 722.6, Degeneration intervertebral disc site, unspecified. For ICD-10, you must code all claims to the highest level of specificity. Note that the unspecified code in ICD-9-CM does not map to an unspecified option in ICD-10-CM. There isn't a degenerative intervertebral disc site unspecified in ICD-10-CM, since physicians know the specific level of the degeneration if their intent is to treat the site, as the table below shows.

ICD-10 Degenerative Disc Disease Diagnosis Codes

M51.34

Other intervertebral disc degeneration,
thoracic region

M51.35

Other intervertebral disc degeneration,
thoracolumbar region

M51.36

Other intervertebral disc degeneration,
lumbar region

M51.37

Other intervertebral disc degeneration,
lumbosacral region

— Cristina Bentin, CCS-P, COC, CMA

It doesn't end here
This October also ends the partial freeze on ICD-10 updates, which means updates for the 2017 coding schedule are set to resume and take effect in just a few months. The healthcare industry is getting roughly 5,500 new ICD-10-CM diagnosis and ICD-10-PCS procedure codes. There will be roughly 3,600 new or revised ICD-10-PCS codes, and 1,900 ICD-10-CM codes, with the latter being phased in within the next 2 years. You can view ICD-10-PCS updates (osmag.net/Hhg4HF), but as of this writing ICD-10-CM updates have not yet been released.

Now's a good time to review all new, revised and deleted ICD-10 codes to assess the impact these additions may have on your facility. Surgical centers are not required to report ICD-10-PCS codes, so ASCs can focus on the 2017 ICD-10-CM updates. All facilities should:

• Review the 2017 ICD-10-CM updates that go into effect Oct. 1. (Hospitals should also review the ICD-10-PCS codes.)
• Educate business office and clinical staff as soon as any updates are accessible (they should appear on the CDC's website once available).
• Review operative reports and documentation to verify whether the new diagnosis codes are supported.
• Verify that the code changes will be added to your current software and electronic health record system. OSM