ICD-10 ‘grace period’ ending soon, but don’t panic

We are a mere 2 months away from the anniversary of the great ICD-10 implementation. Oct. 1, 2015 turned out to be a Y2K-like non-event, with relatively few hiccups for most physician offices. The smooth transition was due, in part, to the agreement by Medicare and several other private payers to delay denial of claims and suspend chart audits based on lack of specificity of the ICD–10 code(s). The American Medical Association requested this phase-in, or “grace period,” which ends Oct. 1, 2016. 

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By now, most of you are relatively fluent in the urology diagnosis codes that affect payment for the services provided in the urology office. Of course, we are now facing the end of the “grace period,” and fears of denials for bad diagnosis codes are once again starting to circulate. This begs the question, what should you do now?

Although it is not time to panic, it is time to look at your next steps. The first step in planning is to review the landscape. First and foremost, you need to consider current revenue streams based primarily on the fee-for-service market. For the average urology practice, Medicare and related federal payers will cover most of your patients, so Medicare is the obvious place to start.

Medicare has stated that beginning on Oct. 1, 2016, it will begin to require more definitive diagnosis codes and will no longer accept family codes or codes that are unspecified. We have received many questions seeking clarification on these points.

LCD process remains

For some urology codes, the end of the grace period will have no impact. Medicare has not abandoned the Local Coverage Decision (LCD) process that has been in place for many years, nor has Medicare suspended the LCD program during the grace period. This process requires that Medicare publish changes and amendments to any LCD prior to implementation, including diagnosis payment restrictions. In other words, for those CPT codes for which Medicare has or had specific diagnosis requirements for payment listed in an LCD, it will not be implementing a new set of diagnosis code restrictions without a required review and release period.

Action: Continue to monitor LCDs for your carrier. Please note any new diagnosis coverage restrictions that do not make clinical sense. Medicare and other payers are asking for accuracy; in some cases, the most accurate code is an unspecified code. Document what is known for each visit and focus on selecting the correct code. If Medicare has eliminated a clinically relevant diagnosis code, contact your carrier advisory committee urology representative and see if a change can be made.

Unfortunately, payment policies for other payers are not so visible. However, Medicare and other payers all use electronic systems to adjudicate the vast majority of claims. In short, in order to change the allowed diagnosis list for any code, there must exist within the payer’s system the edits to support the CPT diagnosis relationship to either pay or deny a claim.

Action: Monitor claims denials and requests for additional information from the practice. Remember, not all denials are ICD-10 related. For those that are diagnosis related and based on non-specific diagnosis codes, establish a system to communicate these requirements from the billing staff to the clinical staff. This practice should be old hat to most offices. With regard to CPT codes and modifiers, add diagnosis watching and increase your communication.

We have been told of sporadic denials by private payers for claims submitted that include unspecified codes. There are not enough data yet to indicate that this is a widespread change; however, in speaking with some of our payer contacts, they have indicated that it is possible to flag claims for denial or suspend for data request any claim based on any particular ICD-10 codes. If payers elect to use this process, you may start to see this approach to tightening requirements for diagnosis specificity. Based on payer use of similar processing systems, we would expect that if one or two payers decide to use broad denials or suspend claims based on unspecified diagnosis code edits, most large payers will follow suit. Medicare’s comments regarding limiting unspecified codes are more focused on post-service review but nonetheless indicate a general dislike of unspecified codes when more specific codes are available.

Next: "We recommend letting go of ICD-9."

Action: There are two steps we recommend for practices as they continue to refine their diagnosis coding and avoid general denials where possible. First, we recommend letting go of ICD-9. Many practices continue to use old forms, crosswalks, cheat sheets, EHR crutches, and other tools that require looking first for diagnosis codes in the old ICD-9-CM system. It is time to let go and move on (unless you have an EHR that cannot keep up). Shortlists with verbiage that you customize in either paper, cheat sheets, or within an EHR need to be updated to ICD-10 direct codes.

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Updating these forms to ICD-10 or for those who have already eliminated ICD-9, updating these forms for 2016 will need to include the second step, which is to remove any “general” unspecified codes that do not make clinical sense. One obvious example we have run across is C67.9 (Malignant Neoplasm of the Bladder, site unspecified). Basically, if you know that a tumor is malignant, you should know where it is. Another example is R31.9 (Hematuria, unspecified). Our argument is similar; if you find hematuria, you should know at least if it is gross or microscopic.  You should not eliminate unspecified codes that make clinical sense such as N52.9 [Male erectile dysfunction, unspecified], as these codes will still be used for cases in which there is no need to further diagnosis or for which you can prescribe treatment without a more definitive diagnosis.

By eliminating unspecified shortcut codes, you will help remind yourself and your colleagues to be more specific. If you can remove other codes that are infrequently used and replace each code with a more specific diagnosis, do it.

Watch for changing codes

The Centers for Disease Control and Prevention and Medicare announced changes for ICD-10 codes for 2017 ICD-10-CM. Remember that ICD coding both for versions 9 and 10 have been frozen for 4 years. The freeze has ended. They have announced that 2017 ICD-10-CM will contain 1,943 new codes, 422 revised codes, and 305 deleted codes. Luckily, the majority of the changes do not affect urology directly.

In all, we identified 121 changes to codes that would likely affect urology. (Note: We did not count code changes for any chronic diseases that were not typically urologist treated.) Sixty-four of the changed codes were made to the code family of T83 (Complications of genitourinary prosthetic devices, implants and grafts) and T85 (Complications of other internal prosthetic devices, implants and grafts) (added to the list based on the use of InterStim by urologists around the country). Both the full list of proposed changes and those changes identified as affecting urology are posted on AUAcodingtoday.com to assist in preparation for this change.

Action: Begin the process of updating your 2016 ICD-10 file to the 2017 ICD-10 file. Make sure that your practice management system and EHR will have the updated files ready for use by Oct. 1, 2016. Depending on your practice, some of the additions and changes may have limited impact.. However, there are a few new codes that many will find helpful in removing unspecified codes from your short list of ICD-10 codes.

Last but not least, in the fee-for-service world, is the fact that the grace period included Medicare’s promise to ignore ICD-10 mistakes from an audit perspective. The reverse of this, of course, is that Medicare and other payers now have the go-ahead to evaluate non-specific codes and general family codes suspected of being incorrect by reviewing the Medical record. We see this as being executed in both pre- and post-payment reviews.

We have mentioned previously that documentation of service and clinical findings must stand on their own during medical necessity review. A move to increase accuracy will likely result in a few more medical record requests.

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Action: Continue to improve your documentation and data capture, with an eye toward the most specific diagnosis available. Documentation improvement and coding education should remain on every office to-do list year after year. You may need to educate and audit some of providers in a preventive step to help increase compliance and lower risk from audit take-backs.

Next: Don't forget MIPS

Don’t forget MIPS

In addition to the fee-for-service world, you should also begin thinking about the future under the Merit-Based Incentive Payment System (MIPS) and value-based care. Last year, in preparation for ICD-10, we encouraged you to focus your efforts on urology diagnosis. During the move to ICD-10, it was important and remains important to continue cash flow, and urology-specific diagnosis coding is still a primary driver in reimbursement.

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However, as we move to value-based medicine, it is important to include those underlying diseases that may increase resource consumption across the spectrum. Understand that population health, coordinated care, and cost reduction are going to be a focus of health care system changes for years to come. The Medicare value-based payment modifier and eventually MIPS, as well as other private payer initiatives to change the overall cost of health care look beyond urology, but do not look beyond urologists and the possible contribution they can make to general health problems.

While not fair and often generally incorrect, penalties for value-based services that tend to impact future payments have already begun. Diagnosis coding that tells the entire patient’s story relative to health is an important measure for most payers in the current and future markets.

Action: Focus on collecting patient information on important population health diagnosis codes. Specifically, chronic kidney disease, hypertension, heart disease/failure, chronic obstructive pulmonary disease, osteoporosis, rheumatoid arthritis, cancer, body mass index-obesity, and diabetes, which are the current focus of Physician Quality Reporting System measures, should be made top priorities. Education of physicians and non-physician providers and amendments to patient data collection tools can ease the pain of increased data requirements. It is not too early to start working on these long-term goals, as the future as always is closer than you think.

Generally, ICD-10-CM coding is going to expand. Remember, diagnosis coding tells the story of what is currently problematic for a patient. CPT tells the story of what the urology practice has done to address those problems. If you do not tell the whole story from a problem standpoint with accurate codes, payment for the actions you have taken will decrease or at the very least will be delayed. A systematic approach, education, system changes, and increased communication taken in daily actions are best practices and should be a part of yours.

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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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