Post-deadline steps physician practices should take include forming teams across the practice that can track the number and type of claim denials to determine what is causing them.


Sept. 30—In the waning weeks before the historic Oct. 1 transition to the ICD-10 code sets, physician practices reported gaining little benefit from federal initiatives aimed at easing the switch, according to recent polling.

Porter Research polled 318 providers nationwide in August about their organizations’ readiness for the ICD-10 transition, and found few were planning to utilize assistance and flexibility offered by the Centers for Medicare & Medicaid Services (CMS). On Oct. 1, the agency is requiring all HIPAA-compliant providers to switch to the new codes when billing Medicare or Medicaid, and many private payers also will require the switch.

Few survey respondents, most of which were the types of small physician practices that are expected to face the biggest challenges during the transition, planned to utilize non-specific ICD-10 codes as permitted (3 percent), while 74 percent planned to use the most specific codes possible. CMS announced in July that for one year after Oct. 1, review contractors will not reject any previously paid Part B claim based solely on the use of wrong codes, as long as a code from the correct "family" is submitted.

The concession, negotiated with the American Medical Association, has drawn criticism from coding experts for doing little to make the submission of initial claims easier, while also sowing confusion because it would not apply to payers outside of Medicare.

Factors that possibly limited the appeal of the flexibility to survey respondents included the policy’s exclusion of medical necessity determinations and lack of clarity around whether secondary Medicare payers—such as Medigap plans—would follow it, Ken Bradley, vice president of strategy and regulatory compliance for Navicure, said in an interview. 

Additionally, half of the survey’s respondents said their concerns about the switch were not lessened by CMS plans to authorize advance payments to physicians if a Medicare contractor is unable to process claims due to ICD-10 problems. In such circumstances, physicians can apply to Medicare administrative contractors for a single advance payment for multiple claims during an eligible period of time, according to a CMS FAQ. Thirty-two percent of respondents said their concerns were mitigated by the CMS offer.

“There was a little bit of a sigh of relief that Medicare—in the event that they make a mistake—is going to proactively do advanced payments,” Bradley said.

Reduced Testing

CMS offered three rounds of end-to-end testing, as well as the chance for providers to individually submit claims as part of acknowledgement testing right up to Oct. 1. But the share of providers opting out of end-to-end testing with any payer jumped from 10 percent in a separate survey at the beginning of the year to 38 percent in the recent survey.

About half of the respondents either planned to engage in end-to end testing or had completed it. Among those that completed such testing, none reported surprising or negative results.

However, varying rates of success in CMS’s three rounds of end-to-end testing over the last nine months raised concerns among some payment consultants that many practices could face significant revenue impacts from ICD-10-related payment denials.

That concern was echoed by the respondents to the recent survey. More than half were only somewhat confident or not confident that they would be ready for ICD-10, and the majority (56 percent) named ICD-10’s impact on revenue or cash flow as their biggest concern. Seventy-one percent of respondents expected their denial rates to increase by at least 11 percent after the transition.

Specific challenges during the transition as identified by respondents included increased clinical documentation updates and coding issues  (31 percent) and a lack of preparedness by payers resulting in a lack of payment (27 percent).

Many commercial payers have said they are prepared for the transition, and Bradley was “hopeful” that was the case, although similar promises proved untrue during the 5010 claims transition.

Provider Responses

The leading responses planned by providers were improving their patient collections process (34 percent) and denials management process (30 percent).

On the day before the transition, Navicure concluded more than 98 percent of its clients at least had the software in place to send the ICD-10 values. However, it remained up to the providers to send the accurate values, which was why Navicure encouraged providers to take the time to review their coding values to ensure they match the clinical documentation.

Even after the changeover, according to the consultancy, providers should form teams from across the practice that can review real-time denial and rejection results to identify the types of denials that are increasing and the common causes of those denials.

“It takes a team effort to eliminate some of those types of problems,” Bradley said.

Another step providers should take is to closely follow communications from payers and vendors to be able to respond quickly to issues that develop.

Regardless of the CMS flexibility, practices should strive to use the most specific possible ICD-10 codes, given that those will be required over the long term.

“That means that they may need to look at some short-term—hopefully—reduced productivity rates so that they are watching and monitoring and measuring things to make sure that they are accurate during those first few weeks and months of implementation,” Bradley said.

Meanwhile, Navicure plans a follow up survey sometime before the end of the year to see how the transition has gone. That polling comes in addition to efforts by CMS and private consultants to track adverse impacts from the switchover. Among the industry efforts is ICD10Central.com, where key performance indicators—including days to final bill, days to payment, denial rate, and reimbursement rate—for RelayHealth customers will be tracked.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Wednesday, September 30, 2015