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

    Letting go of ICD-9, avoiding/eliminating unspecified codes can help you prevent denials

    Ray Painter, MDRay Painter, MD Mark PainterMark Painter


    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."

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.


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