Submitted by Antonio Arias, MBA, CHBME on Tue, 09/6/2016 - 8:00

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3 Surprising Consequences of the Shift to ICD-10

Following years of arguments, delays, and controversies, the shift to the ICD-10 code set has gone relatively smoothly since its mandated transition date of October 1, 2015. Almost a year later, the code set’s full implementation is almost upon us: On October 1, 2016, the ICD-10 “grace period” comes to an end.

What does that mean? Namely, that the “unspecified” use of an ICD-10 code, minus the most specific modifier, will no longer be A-Okay under the Medicare guidelines. (For example, medical practices today can still leave it unspecified whether they’re treating an injury on the left ear or right ear when selecting an ICD-10 diagnostic code for the bill. At present, that’s not reason enough for a claim denial. Come October 1, it may be.)

So as the more lax moment in ICD-10’s early history comes to a close, it’s time to investigate how the increased specificity of ICD-10 is beginning to impact the medical billing and healthcare fields at large. Here are three interesting consequences thus far.

New Business Opportunities

By supplying the healthcare industry with a more standardized, specific, and broad set of codes, ICD-10 will (ideally) deliver higher-quality data to the sector at large. Interestingly, however, it may also create more opportunities for the private sector to benefit from increased application and use of more specific codes.

Case in point: The CMS recently created a new code for “a nanotextured surface on an interbody fusion device” when releasing a collection of new and revised codes in June 2016. Shortly after, Titan Spine announced that the company is preparing to roll out meets those criteria, and is the only set of devices that has been approved for use of the code – with its CEO noting that the new code was “a big selling point.”

EHR Data Quality Comes Back to the Fore

The soon-to-end ICD-10 grace period wasn’t originally a given. In fact, the American Medical Association pushed hard for the exemption, arguing that physicians should not be penalized due to data quality shortfalls that resulted in incorrect ICD-10 codes. As time runs out on the breathing room of unspecificity, the data quality issue is regaining attention.

Clinical documentation improvements are underway across the healthcare sector, however, and every industry change – medical billing-related, or otherwise – causes some level of strife among providers. This will be an issue to watch (but hopefully one that passes with as little fanfare as the October 1 shift did).

Diagnosing Dilemmas Arise

Now that increased specificity is (almost) an unavoidable requirement, physicians face interesting concerns when coding, as Allen R. Frady writes in ICD-10 Monitor, more “dicey” diagnoses that may be unsupported by the clinical circumstances reflected in the medical record. Frady notes that it’s a catch-22 scenario: “If the diagnosis is not clinically validated, then both Recovery Auditors (RAs) as well as commercial insurance auditors are going to deny the claim. On the other hand, if the coder or the facility decides not to report the diagnosis, then they are in violation of the coding guidelines, which is also a major problem.”

Ideally, such circumstances arise rarely. (And as Frady notes, ultimately physicians will code what they code, insurers will deny what they’ll deny.) Hopefully, however, code-related concerns won’t lessen the quality of data – or care – delivered to patients and the industry at large.

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Topics: Meaningful Use Stage 2, Practice Management, Medical Billing Company

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