In the end, perhaps the hardest part of the ICD-10 launch was simply getting to it. After years of ‘sky is falling’ prognostications surrounding the changeover, the launch date of Oct. 1 came and went pretty quietly.

Of course, the numerous delays and a compromise hammered out this past summer between the Centers for Medicare & Medicaid Services and the American Medical Association regarding a grace period for providers, might well have contributed to the relatively smooth kickoff.

“People have just done a tremendous amount of work over the last four years for this transition,” said Ed Hock, managing director for Revenue Cycle Solutions at The Advisory Board Company, a national healthcare research, technology, consulting and performance improvement firm.

He added the issues that cropped up in the wake of the launch tended to be relatively minor technical glitches. However, Hock noted, any kinks in reimbursement or cash flow probably won’t show up until this month or beyond as bills begin to make it through the claims processing cycles of payers around the country.

Helping physicians during the transition to the much more complex diagnostic coding system is an audit and denial moratorium (for specificity) granted to practitioner claims submitted under Part B for a period of 12 months. CMS has also installed an ICD-10 Ombudsman to help triage provider issues.

Hock, who works primarily with larger health systems across the country, said it’s important for those in the industry to understand the caveats attached to the moratorium. First, he noted, “The grace period only applies for the physician portion of the claims.”

Hock added that for inpatient claims, hospitals need to get it right from the start. “The professional portion of the claim still has the grace period but not the technical portion of the claim,” he explained.

Hock continued, “Even in the professional portion, the physician has to use an ICD-10 code, and the code has to be within the correct family so the physician has to make a good effort.”

For example, a provider bill coded for pneumonia under ICD-10 should still be paid even if it the practitioner didn’t drill down far enough to note this was a second occurrence … or if an office visit was billed for acute serous otitis unspecified, when it really should have been coded for the left ear.

Hock again noted that hospitals do not have that same luxury. “Hospitals are very much at risk for denials, audits and lower reimbursement based on codes,” he said. “It does set up a potentially difficult situation for hospitals because they are so dependent on the physicians practicing in their hospital getting the codes and documentation correct, while that same physician has a grace period for his or her claims.”

From his observation, hospitals and health systems that have worked with both contracted and employed physicians to thoughtfully train them on the importance of detailed documentation have the best chance to be successful. “What’s most effective is showing them the impact full and complete documentation can have on their quality metrics such as observed vs. expected length of stay or observed vs. expected mortality rate,” he said.

“Once physicians see how a few words in a patient’s record can dramatically change how they measure up to their peers in these categories, they are much more willing to spend an extra moment ensuring the documentation is complete,” Hock continued.

He added that outside of the coding and payment side of the equation, ICD-10 offers a tremendous amount of information and analytics to physicians that could be used to better inform decisions. The question, Hock noted, is “How do we, as a system, begin to use this data to improve care?” While that answer might not be immediately known, Hock said the potential is exciting.

Circling back to reimbursements, Hock said even if concerns are somewhat mitigated for individual practitioners and their office staff over the next months, it’s still crucial to make every effort to use the exact diagnosis code … both because codes have to be in the right family and because the clock is ticking on the grace period.

“This is a golden opportunity for them to practice in an era without penalty so they need to make sure they are periodically calling in outside auditors or having an office manager do spot checks. That way when the grace period ends on Oct. 1, 2016, they are prepared,” he said.

“Practices don’t want to fall into a false sense of security. Working towards correct documentation and coding will set them up for success in 2016,” Hock concluded.

RELATED LINKS:

The Advisory Board Company: www.advisory.com

Advisory Board ICD-10 Services: https://www.advisory.com/solutions/icd-10-transition-services

CMS ICD-10 Resources: https://www.cms.gov/Medicare/Coding/ICD10/Index.html