ICD-10 testing isn’t going away — for the most part, it’s not even being delayed. That’s why many payers, including Medicaid, are taking advantage of the additional time before implementation to conduct more end-to-end testing.
What does this mean for providers, payers, and clearinghouses? And how can these groups work together to create richer, more productive, and ultimately more valuable ICD-10 testing initiatives?
The best first step for providers is creating granular, detailed test claims. Actually, though, that’s the second step, because detailed claims start with detailed clinical documentation.
While it sometimes still will be appropriate to use unspecified codes under ICD-10, relying on them simply because documentation isn’t sufficiently detailed will make it more likely that your organization will be audited by payers. And that’s only one reason to improve the quality of your clinical documentation. Detailed medical records and specific coding create a clearer picture of each and every patient. That’s critical for value-based care models, and it’s also just the right thing to do. Put yourself in your patient’s shoes — wouldn’t you want your doctor to record everything about your condition?
For hospitals, these details often determine the diagnosis-related group (DRG), which in turn determines payor reimbursement. For physicians, lack of detail increases the likelihood that a claim will be flagged for failing to demonstrate the medical necessity of the service provided.
Providers that already have completed internal testing may need to create different claims for testing with payers. Focus on the types of claims that have the greatest impact, including your most common scenarios and claims for particularly high-dollar amounts. Identify the scenarios that tend to result in stalled or denied claims under ICD-9 and use the results to adjust ICD-10 training and testing. Uncovering the source of your denials delivers immediate benefits and ensures that you won’t stack ICD-10-related rejections on top of those you could have reduced between now and the implementation date.
Also, start submitting test claims now; don’t wait until the last minute. Some payers have limited windows for testing, andyou don’t want to miss opportunities to test with your most important payers.
Focus on the payers that handle the majority of your claims volume. Talk to your clearinghouse about those payers’ testing schedules and requirements. If your system or vendor can’t yet produce ICD-10-coded claims, your clearinghouse may have an online testing system or other resource that enables you to proceed with testing despite the technical limitations you’re facing. Even if your payers aren’t testing right away, go ahead and submit test claims to your clearinghouse; that way, your clearinghouse has your test claims on file and can simply send them on to payers as testing becomes available.
Payers need to provide clear, precise details about why ICD-10 test claims get denied or rejected. The better providers understand the new code set and requirements, the cleaner their claims will be after implementation. If you’re a payer, it’s in your interests to help providers improve their ICD-10 coding. Helping them now preemptively reduces your potential ICD-10-related backlog and call volume down the road.
In an ideal world, payers would work together to standardize ICD-10 testing requirements. They’d provide a straightforward, detailed list of ICD-10 requirements and rejection reasons, including examples of what they wouldn’t reject under ICD-9 but will reject under ICD-10. They’d help providers understand the changes.
Of course, some of this information is contract-specific or proprietary – and providers and clearinghouses understand that. But payers should share what they can. Giving this information to providers and clearinghouses helps ensure that coding and edits are as comprehensive and accurate as possible, and this results in cleaner claims.
One last recommendation to payers: be explicit about the claims you want to test. Clearinghouses can help source claim types and provider types and can help you broadcast your requirements and testing schedules. The Centers for Medicare & Medicaid Services (CMS) realized this and experienced great success in its testing week when it included clearinghouses in its call for volunteer submitters.
Clearinghouses can help take the mystery out of ICD-10 testing. There are bound to be some problems experienced by most or all providers, and the clearinghouses that work with many types of providers are positioned to identify those problems and highlight them for their clients – and then recommend solutions.
Clearinghouses can (and should) provide a summary of testing results by payer to all of their clients. This will offer much-needed transparency and will give providers insight into the payers that fall outside their lists of “major payers.” While it’s not feasible (and maybe not even possible) for providers to test with every single one of their payers, a snapshot of all their payers’ testing results is a valuable resource for staff who occasionally may be called on to submit claims to those payers.
The Year Ahead
These recommendations aren’t comprehensive — I’d need to spend a lot more time with you to share every useful tip. But I hope they get you thinking about how to approach your ICD-10 testing over the next year, specifically regarding what to look for from your payers and vendors, what to ask of your staff and colleagues, and what you can do to help your organization get the most out of ICD-10 testing. Above all else, stay engaged; the delay is a call to action, not an excuse to put off your preparations.
About the Author
Betty Gomez is the vice president of regulatory strategy at ZirMed and a member of the Cooperative Exchange.
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