ICD-10 Challenges and Revenue

You have ‘heard’ ICD-10 is complex. You really don’t know because I don’t think you have the time or inclination to dive into it, yet. Most of you will depend on your support system to help you – your Academy, your EHR vendor, your Biller, and so on.
It is a dual-edged sword. One of the promises of ICD-10 is the potential for enhanced granularity, laterality, and overall reporting accuracy. This is particularly important to providers because insurers use ICD to determine reimbursements based on the medical condition of the patient and the procedure(s) used for treatment. What granularity does for CMS and insurers, i.e. provide better reporting, can become a nightmare for providers because more granularity means more work for you. You are doing the heavy lifting on their behalf.

Your first concern should be to ensure that the codes correspond one-on-one with your current reimbursement structure. You do not want to choose a ‘wrong’ code that causes underpayment. Sure, I think it will perhaps be difficult to find exact one-on-one matches for all codes from a treatment and reimbursement perspective for each encounter and claim, but perhaps on an aggregate level, your goal is to ensure your overall reimbursement level remains the same.

ICD-10 and Reimbursement

Improper and incomplete coding can increase denial rates, causing significant revenue loss. Migration to ICD-10 could result in significant over- or underpayment when using DRG-based reimbursement. Here’s a real example I found at Edifec’s website.

ICD-9 Code 6149 is categorized under MS-DRG 759. When converting to ICD-10, ICD-9 Code 6149 can be mapped to two different ICD-10 codes: N735 or B3749. These map to DRG 759 (same as ICD-9) and 690, respectively. The resulting payment in the second case is about $6,000 more than what would have been paid before the ICD-10 transition.

This example shows that payment variation under ICD-10 can be cut both ways. If a provider organization can’t quantify its risks, it may end up dealing with unfavorable payer contracts, longer collection cycles, and uncertain financials.

Of course, this type of analysis can be very time- and labor-intensive. Providers and payers should work together to identify and prioritize areas of risk, based on actual historical data. Analyzing a provider’s own data based on reality-based ICD-9 to ICD-10 mapping scenarios delivers the “street-level view” of the real operational and financial risks posed by ICD-10 to the organization, rather than just a list of every possible risk.

Your EHR / PM system should allow you to generate reports that analyze the reimbursement by codes so that you can use these when you talk to payers and when you map out ICD-10 codes.

Make it Work

Therefore, while there is a lot of fear, you can make it work for you. Your EHR/PM system should help you ease some of the pain by providing proper mapping tools. Talk to your vendor and make sure they know what they are doing.

Author: Chandresh Shah

Chandresh Shah specializes in Healthcare IT and Medical Billing. He knows the market inside out; what works, what doesn’t. He advises and works with small business owners.