CMS predicts that claim denial rates could skyrocket by 100% to 200% in the early stages of ICD-10 coding
Some of the prominent senior industry analysts also expecting that more claim denials are looming on the horizon. But, here in Promantra we were able to defeat the ICD-10 deadline and reached the Paramount.
Now, geared up to confront and avoid the related denials... Question is HOW?
During the success meet today in the morning, our Coding specialist Chandramouli explained five creative strategies which helped the team to achieve this outcome. I have put these in brief description below and thought to share with my LinkedIn friends. Hope this will be useful to you.
1) Since the last Jan’15, Team was carefully following the CMS instructions through emails to deal with the ICD-10 transition such as below key five steps :
- Make a Plan
- Train Your Staff
- Update Your Processes
- Talk with Your Vendors and Health Plans, and
- Test Your Systems and Processes
Promantra coding team prepared itself to stick to these five key steps for the transition process
2) Designed the below internal transition plan and adhering to the timelines
3) Trained the Promantra staff on ICD-10 basics & principles based on the opulence of free resources from CMS, which include the ICD-10 portal, Road to 10, Email teasers, National Provider Calls, and webinars. Free resources are also available from:
- Medical communities, health care professional societies
- Hospitals, health plans, vendors, health systems
4) Below are the four important elements that team worked to ensure they are acquiring proper data and information to avoid predicted denials in regards to ICD-10:
Calculate or assess – Measured the current basic rate of claim denials and/or rejections. Based on some prominent Denial experts, over 2 billion payer specific claim edit codes are being used, but only a part of these codes account for the majority of the denials. Identify top denials now so you can focus on operational fixes before the ICD-10 transition.
Evaluation - Organization’s current documents and material should support the specifications of ICD-10 coding. Analyzed the last 3 months patient charts as clinical staff members are capturing the required details for selecting the right ICD-10 code. Based on the findings and observations, provided necessary feedback to the clinical staff unit.
Training – Provided required training to all Promantra coders to handle the increased complexities of ICD-10 coding. Also, conducted assessments on the same to check their knowledge levels.
Billing Testing: Performed trial based billing for one month to see if the claims get through the machines with ICD-10 codes billing based on the top Dx & CPT codes we use most.
5) Initiate Denial Management process
Established the formal denial management strategy led by a separate team. This is the Strategy which is able to forecast and alleviate the most common denials that are likely to occur in ICD-9 or ICD-10. Below are some of the common denials that experts say will be particularly challenging after ICD-10 implementation and the strategies to control these denials
Technical Denials - These denials are certainly expected as soon as ICD-10 is implemented, however considering the technical glitches of transitioning to an entirely new platform of coding system.
Solution: The best way to mitigate this type of denials is to ensure that accurately coded test claims are scrutinized through a formal outright testing process. Performed the testing with almost all possible payers to ensure the smooth transition process.
Logical Denials - Logic based rejections may occur when the ICD-10-PCS or CPT codes do not logically match the corresponding ICD-10-CM code. For Eg: Carpal tunnel syndrome specifies left or right. The Dx code should match any corresponding CPT code. Solution: Hospitals may rely on claim scrubbers to filter these types of rejections. However, physician practices with less sophisticated applications and tools may face a more difficult time. Coders started maintaining the typical surveillance on the Dx codes that specify laterality to control denials.
Unspecified Code Denials - Though unspecified codes may not have serious financial implications today, many experts predict that this will change in ICD-10. Solution: Identified the current unspecified percentage in ICD-9-CM and tracked it. An unspecified rate of 18-20 percent with ICD-9-CM is well known and common, and the goal is to control this baseline from increasing after ICD-10 is implemented in Promantra which is since July’15.
Invalid Code Denials - Organizations that grapple with invalid code denials in ICD-9-CM may similarly find ICD-10-CM to be particularly challenging. Solution: Ensure that coders received proper training and awareness on these types of denials. Denial management team also focused on these elements. However, it also depends on assigning of codes correctly in the first instance which will automatically mitigate this challenge.
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