There are two reasons mistakes happen
Claims and coding errors occur for two general but distinct reasons: 1) information about the claim is missing or inconsistent; or 2) the indicated diagnosis and procedural codes are inappropriate for the type and level of care.
In the first case, there are systematic and largely automated w
Greg Larson, director of services, product management,
The TriZetto Group
ways of confi rming that a claim record is compliant with standards established for required data present (i.e., date of birth is present) and that the data is consistent (i.e., the zip codes match the state
references). The second case presents a larger challenge and is likely to be a signifi cant source of errors as a health plan transitions its systems to ICD-10. There are three key steps to mitigate a substantial
increase in claims and coding errors from inappropriate or incorrect ICD-10 codes:
Step 1: Collaborate and communicate. Payers and
providers should invest now in training and certifi cation programs for medical coding staff, nurse resources, CMOs and other healthcare professionals who will assign or evaluate ICD diagnosis and procedure codes. Step 2: Determine your codes. As soon as possible, both payers and providers should begin evaluating the relationships between the ICD-9 codes in use today and the medically equivalent ICD-10 codes to be adopted. Step 3: Test early and often to validate that both the payers’ and providers’ ICD-10 code usage is consistent with clinical accuracy and medical policy regarding benefi ts and treatment coverage.
Key to reducing errors is education
Education is the best way to reduce coding and billing errors as we transition to ICD-10. I’m certainly not the fi rst to talk about the importance of education, which is admittedly a very broad and general term. The key will be breaking that broad focus on education into a few distinct, manageable goals. Right now, practices should be assessing the new ICD-10 code sets. There are a number of resources that map out how ICD-9 will “translate” to ICD-10. Although these conversion maps are not 1:1, they still provide solid educational opportunities. Providers and coders alike can see what the new ICD-10 codes look like, how they are different from current ICD-9 codes and how coding and documentation will need to change come Oct. 1, 2013.
Once providers and coders understand the new codes, www.healthmgttech.com t
D b e s c
Ken Bradley, VP, strategic planning, Navicure
they then must educate themselves about their own practice’s coding patterns. It will be essential to understand the top 10-20 diagnosis codes billed – or at least those diagnoses that account for the largest percentage of practice revenue. Drill down into the particulars of those codes; become familiar with what the conversion will entail for those specifi c codes. Failure to do this successfully will create serious risk for revenue- cycle disruption. Additionally, practices should vigilantly monitor
key offi ce metrics. Develop benchmarks and then monitor each metric by provider and payer to ensure reimbursement does not dip as the nation
switches over to ICD-10. While these pieces of advice are not comprehensive by any means, they provide a starting point for practices to ensure that revenue cycles remain steady.
HEALTH MANAGEMENT TECHNOLOGY July 2011 9
Successful ICD-10 transition requires planning and collaboration
ICD-10 is coming – and while it will surely offer advantages, it’s going to big and expensive, and there are going to be problems. So here are some tips for helping your organization to get ready.
• Evaluate all your systems to ensure that you’re prepared for the changes. Any place an ICD- 9 code is displayed or utilized is a potential point for change. Billing systems are obvious – but there are places throughout your major HIS systems and your niche products that use the current ICD-9 coding nomenclature and rules.
product manager, PatientKeeper
• This is a group activity. There’s no one person who will be able to do everything. We share responsibility as vendors and providers for ensuring that we understand the codes that document care and then charge appropriately. Your vendors want your help in making this as foolproof as possible.
• There are many great resources and practice tools available from CMS and others. Use those tools now, examine the mapping templates and ensure you’re familiar with the new structure.
Anything you can do to get ahead of the curve is a good thing. Using appropriate automated tools that are available and mapped today to ICD-10 takes the mystery out of many of the changes. Knowing that your vendors are already prepared to support the structure, volume and code edits that you need them to handle will make the process seamless in the end and allow you time to build out the changes now.