On October 1, 2015, US health care providers, payers, and other health care entities transitioned from the ICD-9 to the ICD-10 code set, a transformative change nearly twenty years in the making. In the first few weeks after the national transition to ICD-10, provider organizations are evaluating how the transition will impact their business. Will net revenue be impacted? How will reductions in coder productivity affect organizations’ long term resource needs?
Early reports indicate providers are seeing minimal inconveniences, most of which can be attributed to minor changes in system configuration, edits related to split billing, requests for re-authorizations for services in the new code set or updates needed on paper documents that were missed during the preparation activities. However, some believe we have just begin to scrape the surface of potential disruptions. Through initial responses from payers, reviews of key performance indicators (KPIs) and regular huddles with their revenue cycle teams, providers can better prepare to deal with these uncertainties and minimize the long term impacts.
Some ways providers can mitigate the risks include:
- Monitor net revenue shifts: Keep a critical eye on any impacts to net revenue changes based upon changes in payments, case mix shifts, coding accuracy impacts or movements in diagnostic-related groups (DRG) trends as compared to ICD-9.
- Track physician clinical documentation queries and responses: Look for swings in physician queries. Increases could identify opportunities for physician education or updates to electronic health record (EHR) templates. Decreases could identify opportunities for coders and clinical documentation specialists. Start to consider how to provide follow up education based upon results.
- Monitor coding productivity and accuracy: Review productivity and accuracy of coders. Consider engaging an external vendor for an outside audit of ICD-10 coded cases and to backfill for staff shortfalls related to decreased productivity.
- Observe cash trends: Watch for cash flow by payer and compare against ICD-9 values. If cash is delayed or lower than expected, check possible root causes such as increased discharged not final billed (DNFB) and charge lags, or changes in contracts that may have impacted reimbursement rates.
- Track and trend payer rejections: Watch for trends in unexpected payer rejections and reach out to your payer partners to investigate root cause. Some of these errors could be due to incorrect logic on either end and can be easily corrected.
- Analyze denials: As denials come in, look for changes in reasons related to coding and authorizations. Increases in these denial reasons could identify opportunities for staff training and process changes to minimize denials in the future.
- Review adjustments: Monitor contractual adjustments and write-offs to ensure claims aren’t being accidentally adjusted when additional payments can be received. This would include medical necessity and Advance Beneficiary Notice (ABN) adjustments. While some of these adjustments may be appropriate, they may also lead process changes within patient access.
With an industry wide upheaval of this size, there is bound to be a time of uncertainty. However, planning based on initial indicators will allow provider organizations to be prepared to identify and ultimately address issues as they arise over the coming months.