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November 17, 2015
The Revenue Cycle 3: Submitting Clean ICD-10 Claims

Now that ICD-10 is here, it’s more important than ever that you submit clean claims for services provided to Medicare patients, as well as those with private insurance. Early reports indicate that the denial rate since the transition to ICD-10 is hovering around 10%. That’s at the high end of the industry-average range of 5 to 10%, which must be further minimized to ensure a smooth revenue cycle. Here are some ICD-10-related challenges to submitting clean claims, and what you can do to avoid denials.

Changes to the coding approach are required

It may be — for a while, anyhow — more difficult than ever to submit clean claims. Although the change to ICD-10 did not affect how codes are reported, including correct modifier placement, there are nearly 19 times as many procedure codes under ICD-10 and five times as many diagnosis codes as there were under ICD-9. Inevitably, there are some key changes to the approach a coding-set expansion so large. A few examples:

  • Some codes are now combined. For example, in poisoning codes, only one code is needed to convey poisoning, substance, intent and encounter. This reduces the need to report two codes to capture one condition.
  • Some codes are now separated out. For example, in obstetrics, the first, second and third trimesters are all identified separately, which will allow better data collection and analysis.
  • There are new “excludes notes,” which can signify one of two things. Excludes 1 means, “don’t code here,” and Excludes 2 means that something is “not included here, but may be reported as an additional code.”
  • Laterality has become more specific. Coders will be able to differentiate right from left, and even indicated that a service or diagnosis was bilateral, as needed.
  • More specificity is the name of the game. Codes may run to six or seven characters, depending on how honed and descriptive they need to be. More on that in the next section.

Valid codes require the right level of detail

Your coders also need to have encyclopedic recall of the new alphanumeric (instead of numeric) categories, as well as the new chapters, titles and condition groupings. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. The category alone is not enough — the right level of detail, often requiring more than three characters, must be used to ensure a valid code. Real-time coding, performed at the point of service by providers fully trained in and facile with ICD-10, can help ensure the right level of detail is recorded, to guide your back-office coding and billing staff in creating valid codes and submitting clean claims.

Thorough documentation is no longer optional

To meet the specificity and burden of proof required by the ICD-10 code set, detailed documentation is a must. Each patient record must contain all the information needed to verify the case history, need of service documentation, procedure documentation and patient medication history. Using medical scribes to record the patient encounter as it happens frees up the physician to elicit the required of level of detail, while simultaneously ensuring that those details are recorded for coding evidence. As you seek to minimize denials, it’s a good idea to undertake quality checks before submission. Team your coders to perform code reviews for each other — checking the documentation against the codes that have been generated, and flagging any questions or issues, so that modifications are made before submission of clean codes.

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