8 days to go till ICD-10 replaces ICD-9. Your software vendors and most of the large payers are probably ready by now. As for you:

• Train
• Practice and repeat

Your change management skills will be tested on the big day. Don’t let nerves take over. The best way to keep nerves at bay is to know what to expect.

Here are a few pointers to help you understand how your claim submission process will change and what to do about it, come October, 1:

Use of ICD-9 in four states

Medicaid programs in California, Louisiana, Maryland and Montana have been granted a temporary ICD-10 deadline extension because of the inability of their claims processing systems to perform payment calculations using the new ICD-10 codes. If you are a Medicaid provider in these states, you will be cross walking backward in your ICD-10 ready systems to code and submit claims in ICD-9 to Medicaid.

Use the Upgraded CMS-1500 claim form

Bid farewell to old claim forms which accommodated diagnosis codes up to 5 characters only. With ICD-10 approaching, the new CMS-1500 claim form has been introduced, which consists of updated fields to accommodate ICD-10 code structure up to seven characters.

This form will help in easing the transition for practices because it involves fields, where one can specify which ICD is being used for e.g. a “9” in the required field, would indicate you’re using the outdated ICD-9, whereas a “0” would suggest you’re using ICD-10.

Furthermore, it consists of 12 diagnosis codes as opposed to 4 in the old one. This allows you to further code each patient’s encounter in the most specific and accurate way possible, e.g. in cases involving external cause codes where you can submit as many external cause codes as you want to clearly demonstrate the patient’s condition.

To avoid any discrepancies, remember to communicate with your software vendor the timeline needed to incorporate this new version of the form.

ICD and CPT codes are two sides of a coin

Note that after the implementation of ICD-10, CPT codes will remain unaffected. Outpatient facilities will not be affected and the use of CPT codes will continue after the deadline date to report services and procedures.

Many will breathe a sigh of relief thinking that they do not need the training which ICD-10 demands, since CPT codes aren’t being affected.

This is a huge misunderstanding because even if you know the ins and outs of all CPT codes and understand how they affect your reimbursement; they will still have to be paired with ICD-10 codes on the claim.

In this scenario, if your diagnosis codes aren’t correct, your claims will be denied. Both of these are entwined with one other. Hence, do not think that you can escape ICD-10 just because you only deal with CPT codes.

Denials Due to Referring Provider Issues

According to CMS guidelines “Medicare will deny certain equipment and supplies unless the ordering or referring physician is properly identified and enrolled in certain Medicare systems.”

These include various prosthetic and orthotic equipment and other durable medical supplies. To avoid such denials, make sure your specialty type is properly identified, and you are enrolled in Provider Enrollment, Chain, and Ownership System (PECOS).

4 diagnosis pointers allowed per service

The current HCFA 1500 form allows for 4 diagnosis pointers per service line. Although as previously mentioned, you can list up to 12 diagnosis codes on a single claim form, only four of these will map to a specific CPT code.

So what’s the point of including all these extra codes when only 4 can be mapped to your services?

Consider this example. A patient visits your clinic to get his sore throat checked but ends up getting a thorough evaluation which reveals that he’s had a previous lower leg amputation.  Now, although this visit didn’t address the leg in particular, documenting the diagnosis is still required.

Although there is room for only four diagnosis pointers to one service, if there are other relevant diagnoses made, they will be documented but not specifically pointed out.

Code multiple diagnosis codes in order of Significance

When including multiple diagnosis codes on a single claim, it’s important to code them based on their order of importance. List the primary codes first followed by the rest.

Be mindful that there is no compulsion to include multiple codes on a single claim. Even if you list one code that accurately and specifically describes the patient’s condition, it’s perfectly acceptable to submit that one code alone. Don’t include multiple codes just for the sake of including more codes.

Never include ICD-9 and ICD-10 codes on the same claim.

Remember that ICD-10 transition will include coding according to date of service. According to CMS guidelines:

• Use ICD-10 codes for all services rendered on or after October 1^st
• Use ICD-9 codes for all services provided before October 1^st.
• For claims that have a span of dates of service, split them separately into ICD-9 and ICD-10 codes since both cannot be submitted on the same claim.

Getting these code sets wrong can result in a catastrophe for your practice. For more information read this Crunch time guide to ICD-10.

Identify which codes sets are being used by Non- traditional payers

ICD-10 transition doesn’t mean that no one will be using ICD-9 codes post-Oct 1, non HIPPA covered entities such as worker’s compensation, disability, and auto insurers are exempt from this mandate.

Although CMS is pretty clear about burying ICD-9 in the dirt for good, these entities are encouraged to make the transition at their own pace. That being said, it will be your job to identify which of these non-traditional payers are using ICD-9 and ICD-10 codes respectively and code according to their usage.

At times you will come across patients whose primary and secondary insurances will require different code sets, in this scenario since you can only use ICD-9 codes for payers who haven’t made the switch, you will have to split the claim and send it to the required payer.

Get your billing over with before Oct 1^st

Talk to your payers about their readiness. They need to fully understand the phenomenon of the date of service under ICD-10 transition and handle claims with ICD-9 codes even if they’re submitted post-Oct 1^st.

In the event that they are not familiar with this distinction, your revenues can end up taking a major hit with delayed payments, or worse yet, claim resubmissions.

Make sure you get your billing over with as early as possible, and inform payers about the impact ICD-10 will have on their payment schedule, medical review, auditing, and coverage.

Nobody likes spending hours figuring out why a claim got denied! In healthcare every second counts, and the longer you delay prompt follow up on denied claims, the more your revenue cycle will suffer.