ICD-10 Impact on Covered Preventive Services-

Not surprisingly, compared to the ICD-9 code set, the ICD-10 code set, applicable to preventive services, is greatly expanded and providers need to be certain they are using the code(s) payers want to see on claims for preventive services. CMS has identified, for its covered preventive services, not only the required CPT and/or HCPCS level II codes but also the required ICD-10 diagnosis codes.  I have provided a link to CMS’s Preventive Services Chart below for convenience.  This quick reference identifies, per covered preventive service type, the required coding.

Some commercial payers have also published their coding requirements for covered preventive services. United Health Plan’s guidance for commercial policies is also linked below because it is quite specific and comprehensive.  Anthem BC/BS commercial policies are specific to each state and identify codes “for informational purposes only” and so are less helpful in terms of claim submission guidance.  That makes tracking preventive service claims to Anthem from submission to payment or denial extremely important.  Providers should identify and research coding requirements for any payers with whom they are directly contracted.

Preventive services impact many medical specialties including, but not limited to, family medicine, internal medicine, pediatrics, radiology, gastroenterology, lab/pathology. The negative impact to providers who don’t submit preventive services claims appropriately is considerable.  The negative impact to patients for whom claims are not submitted appropriately is considerable as well.  Copays, coinsurance and deductibles may all be affected, depending on a patient’s plan coverage, and providers need to be certain to submit claims appropriately so that preventive claims are paid from the correct coverage “bucket”.

Much is asked of providers today and we cannot also expect them to know and code to each payer’s requirements for preventive services. Even the Medicare population’s coding requirements are not consistent given that this population’s coverage may include straight Medicare or any number of commercially administered Medicare advantage plans.  For this reason it is imperative that qualified coders review and code all preventive (or potentially preventive services) and then provide education on documentation requirements to providers. Generally, providers should be directed to document to the most stringent guidelines known so that, no matter the plan, documentation is compliant.

Provider practices should analyze preventive services data to determine the impact these services have on their revenue cycle and then put the proper processes and people in place to optimize efficiency, compliance and bottom line.





The Revenue Cycle after ICD-10

Author: Jill Berger-Fiffy , MHA, FACMPE

The planning and implementation of the ICD-10 felt much like a race to the finish. Now in operational mode, it is helpful to begin your “After Action Review” in order to identify potential next steps.    The following will help you craft your “to do list” when managing the revenue cycle.

  • Cash flow-Regardless of whether you submit your claims through a clearinghouse or directly to the payer, be sure to reconcile that every claim reaches the clearinghouse and/or payer.   Delays in payment may be the new reality. Develop a plan as to when and how you will begin to use your line of credit should you have one. Consider the need to reduce or hold the salaries and reimbursements to physician owners.
  • Expense Management-Organize your payables and hold them for as long as possible. Transition from writing checks to the use of bank transfers which can be set up in advance. This allows the practice to hold the cash as long as possible but expedite your payment by the “due date.”
  • Flexible Staffing-Consider the need for temporary staff to review claims and/or work the Accounts Receivable (AR). Productivity for physicians and staff is likely to decrease, thus increasing the overall cost to do the same work. This may be reflected in increased patient wait time and decreased patient satisfaction. If this is the case, workflow verification, analysis and optimization will be essential to ensure the work is completed efficiently.
  • Risk Sharing-Consider the staffing compliment in the practice.       Does the practice have the right staff/enough staff to support the effort required under the new payment schemes and the ICD-10 world?  If you have Certified Coders, prioritize the work to be completed. Ensure Coders are focusing on the “big ticket” items; as well as, those diagnosis categories in which the practice may be at financial risk or in a cost sharing with an ACO reporting effort.
  • Auditing-When auditing medical records, show the physician how the requirements and clinical documentation differ from the ICD-9 to ICD-10. Be aware of the pitfalls of provider documentation. Ensure notes comprise the highest level of specificity and match the diagnosis code selected. Another pitfalls can include the note not capturing the level of specificity reflected in the code or the documentation being very specific and non-specific code is selected. Auditing and compliance review will be crucial in an environment in which specificity, quality, cost and efficiency are all factors.
  • Key Performance Indicators Watch the metrics closely. Carefully monitor changes. Alert your team about potential changes such as increased Denial rate with the clearinghouse and from the payer, percentage of 1st Pass Submission, Days in A/R, Charge Lag, Collection Rate, and Net Revenue per FTE Physician.       Compare past performance by the month to date and to the year over year. Monitor trends by building a dashboard with key measures. Consider using software to assist with denial analysis and analytics in order to maximize revenues.
  • Quality Metrics– It is likely the practice is involved in at least one pay for performance program. Given the many such as Meaningful Use, PQRS, Value Based Modifier, and HEDIS Measures to name a few. You may need to manipulate your data to compare a prior period to the new “current state”. Data manipulation and business intelligence tools will track progress of the practice and provide “actionable” steps. Look for opportunities to improve patient care through workflow redesign.
  • Technology-Ensure the practice is optimizing all of the features of the Electronic Health Record. Confirm the templates and their associated diagnosis codes are updated. Verify departmental and individual lists of “favorites” been updated and are they shared across the department. Review questionnaires, encounter forms, order sets, referral and authorization forms, pick lists for diagnosis used to populate for surgical scheduling forms and of course admissions and discharges. Consider the process for communicating changes and if additional training is now needed. IT staff will need to understand the needs of the end user and be able to “build” the system to meet the requirements.
  • Software-Review the edits/rules in your Electronic Health Record, are they up to date?       Adding coding tools can be helpful, but many times it can lead to the selection of a “non-specific code” which would ultimately be rejected by the payer.   Educate staff on how to use the system and when they should refer to the coding book?
  • Interfaces-Are you using devices or other have programs which interface with your system? If so, has the interface been tested and updated? Confirm if the manufacturer has offered an update version?

In summary, the go live date has passed, but the work has just begun. It will take a multi-faceted approach to remain solvent in this new revenue environment.



Jill Berger-Fiffy

Clinical Documentation Improvement: Challenges & Best Practices

Clinical Documentation Improvement- Far Beyond ICD-10

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The Defining Moments Leading Up to ICD-10

We have now entered into the defining moments of the upcoming ICD-10 Implementation. It’s time to separate the “men from the boys” and the “women from the girls.” It is a time of uncertain change and for those physician practices and hospitals that may have procrastinated, a harsh wake up call. The federal government did not spend millions of dollars preparing their operations and IT systems with no thought to a return on investment. The bottom line? The government will recoup their investment through auditing physicians’ medical records. Paid on commission, the auditor is compensated by finding errors and omissions in physician documentation.

How can you ensure that your clinical documentation will not be contributing to the auditor’s bonus? The best advice I could give would be to stay off their radar by submitting clinical data on claims according to Federal guidelines and regulations. Physician practices and hospitals need staff who are not only skilled, but who genuinely have their organizations’ best interests in mind. Many health systems have come to realize the importance of continued training and education for its employees and providers. With October 1 only weeks away, flying blind and attempting to figure things out as you go is not an option. The consequences for ICD-10 noncompliance are harsh and compromise the reputation of providers and hospitals. Further, it can be humiliating and damaging in several other ways given that audit findings are public knowledge.

Organizations and practices should be positioning themselves for success over the next 10 weeks. Here are some of the tasks that need to take place right away:

  • Complete training for the providers and other clinical staff on ICD-10 documentation requirements and opportunities by working with them directly in the EHR they will use on a daily basis to capture the clinical information. PowerPoints may be helpful as an adjunct tool but, in my experience, the electronic medical record should be pulled up and providers need to walk through actual patients visits of their own or of the organizations case mix step by step, from the inception of the visit to the dropping of the charge. This is the surest way to develop best practices on how to actually capture the specificity in the documentation and in the coding for billing purposes.
  • Make sure there is a denials management process in place and back up staffing to mitigate productivity losses. Co-pays will need to be collected by diligent front desk staff. Obtaining correct, thorough information on eligibility and pre authorizations are critical. Any patient information going into the EMR or EHR demands intentional efforts to focus on accuracy.
  • Remember that “you don’t know, what you don’t know” and as AHIMA tagged in their magazine adds, “What you don’t know can hurt you.” Leverage staff who are highly skilled in many areas (hard skills and soft skills) and who are consistently watching the industry and providing guidance and direction based on what they are seeing. A “feedback loop” needs to be established for the organizations and practices to stand a chance in the fast changing industry of healthcare.
  • Embrace the importance of a culture of collaboration across all areas: Clinical, operational and technical.
  • Determine your contingency plans throughout the revenue cycle operations and around the technology issues that may arise.
  • Communicate, communicate, communicate.

Angela Hickman pic

ICD-10 Delay: Now Get It Done Correctly


Since the delay of ICD-10 until October 1, 2015 at the earliest, many healthcare organizations have questioned what the delay means to their existing ICD-10 implementation programs.   At the time the delay was announced, most organizations fell into one of three categories in terms of ICD-10 readiness:

  • The Prepared
  • Those Getting Prepared
  • Those Who Remain Out to Lunch

Organizations residing in the first two categories expressed frustration at the delay.  They appropriately took control of their own fate, identified and managed risk, and prepared or were preparing their organization for this change.  The third group however either held false hope their EHR/PM vendor would take care of everything, or they were banking on a delay. 

Regardless of which category best describes your organization, the plan forward is simple:  take the newly allotted timeline to get it right. 

Many organizations have delayed other important transformative or IT efforts until after ICD-10 given their limited resources and the work effort necessary just to achieve ICD-10 compliance.  Some organizations took a much broader strategy for their conversion, leveraging this challenge as an opportunity to better enable their physicians and clinical staff to optimize clinical documentation workflows – thus improving quality reporting and patient outcomes.    

With the delay now in place, organizations should absolutely continue implementing their ICD-10 program.  However, the delay does provide opportunities for ensuring the broader success of the ICD-10 program in preparing your organization to more effectively compete in the era of expanding value-based reimbursement models. 

Organizations should take advantage of this opportunity by re-evaluating project scope.  Identify opportunities for including other initiatives into the ICD-10 conversion program in order to more fully streamline clinical documentation workflows.  Ensure your training program is inclusive of new workflows and EHR functionality, not just coding principles and requirements.  Engage payers and intermediaries to ensure your testing program is robust.  Expand your use of dual coding and evaluate reimbursement variance to prepare your organization for the downstream financial impacts.  Optimize the use of informative, specifically predictive analytics and clinical decision support within the EHR. 

ICD-10 poses several risks to a physician practice.  Take advantage of the delay to not only ensure compliance, but also to improve your ability to manage your patient’s health.   

MIR_3989-Brad Boyd

Delay in ICD-10 Implementation: What you can still do now-

The delay in ICD-10 implementation is an opportunity to hone the skill set of your physicians, coders, and clinical documentation specialists.  It is also a time to review your operations and create the efficiencies needed to get the revenue cycle in tip top shape.

Take this time to drill down into your data, analyze your coding vulnerabilities and your potential reimbursement impacts.  Analyze what physicians or what physician services  are needed to develop more specified documentation to more fully describe the services they are rendering and the diagnostic reasoning behind the services or tests ordered.  Continue to have your coder’s dual code a certain percentage of charts per day to develop their skill set. 

Create teams comprised of physicians, coders, CDI specialists and key revenue cycle staff that review the data.  Have the team develop a strategic plan to move the organization closer to an ICD-10 compliant environment.  The plan should include an auditing and feedback loop that encourages the development of more precise documentation from the physicians, while it encourages the coders and CDI specialists to hone their skills and improve accuracy and proficiencies. 

In addition, the strategic plan should include Revenue Cycle Optimization. Revisit your work flows, ask yourself if they are as efficient and as effective as possible.  Examine your denials; how many by type per payer?  Ask yourself why you have the denial.   The root cause analysis will be a valuable exercise and assist you with updating processes, procedure work flows and systems to eliminating the denial, thus increasing cash flow and reducing your accounts receivables and work force hours spent in re-work.

The data analytics and developing a strategic plan on how to utilize the data, will launch you into the great experience of becoming a more finely tuned organization and assist with moving toward an ICD-10 ready organization.

Don’t rely on the Unspecified in ICD-10 CM

For years, we have been consulting providers and teaching “if it wasn’t documented; it wasn’t done”.  ICD-10-CM confirms that not only will you need to document what was done, you need to code for it. The use of  “unspecified” codes has been a common topic of discussion in the industry, even prior to ICD-10-CM.  Some providers became accustomed to “adding a 0” in order to accommodate the fifth digit expansion in ICD-9-CM. This created a growth in the practice of utilizing these “unspecified” diagnosis codes.

 Providers frequently ask “are we going to have payment changes on October 1, 2014 with ICD-10?”  My answer is “Yes” and “No”. Initially, we may not be paid directly on ICD-10-CM codes, but the ramifications of incorrectly utilizing the new codes are enormous.

Some payers will look for reasons to deny the medical necessity of services that providers render and unspecified code usage certainly seem to be the target of additional pre-review questionnaires, denials and even third-party audits. This delay in payment can have a significant impact on your cash flow.

Provider claims can be a review target when you report a Level 4 or 5-  E/M code with an unspecified ICD-9-CM diagnosis code. Payers may presume that this “vague” and “unspecified” diagnosis may not support the medical necessity of the higher levels of  E/M services provided. The correlation can also be presumed that if the diagnosis is unspecified, then perhaps the E/M level might not be properly documented.

It will become even more important to avoid unspecified codes once ICD-10-CM takes place on October 1, 2014.  ICD-10-CM codes are generally more specific in nature and providers need to take advantage of this level of specificity to improve the process of getting paid and to tell the “story” of the encounter more effectively.

The Centers for Medicare and Medicaid Services (CMS) has provided clarification on the use of “unspecified” codes when using ICD-10.  They acknowledge that both ICD-9-CM and ICD-10-CM, “unspecified” codes have acceptable, even necessary, uses.  “While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the health care encounter.  Each health care encounter should be coded to the level of certainty known for that encounter.”

 Many EHR systems plan to use the GEM’s to crosswalk the existing diagnosis codes to the new ICD-10-CM codes. Although this plan sounds good in theory, the level of detail provided in the ICD-10 codes does not provide a direct match in many cases.  The more specific you are currently in ICD-9-CM, the better chance there is to map to an ICD-10-CM.

 An important step in your ICD-10-CM implementation plan is ensuring clinical documentation is sufficient for the new code set.

  • Identify your pattern of unspecified and other specified code use. 
    • In ICD-9, unspecified and other specified can be identified by looking at the 4th or 5th digit of the diagnosis code
      • Codes titled other or other specified are usually a code with a 4th digit of 8 or 5th digit of 9
      • Codes titled unspecified are usually a code with a 4th digit of 9 or 5th digit of 0
  • Identify providers that have a greater unspecified and other specified code usage
  • Target education and review to those providers to use a more specified code in ICD-9-CM, if available prior to the ICD-10-CM implementation.
  • Begin looking at current documentation and “dual code” for the services in ICD-10-CM

The complete, accurate, and detailed documentation of the encounter will be necessary for assigning appropriate ICD-10-CM codes just as it is in ICD-9-CM. Yes, there are “unspecified” codes, but some payers have stated that they are not going to reimburse claims with these codes under ICD-10-CM. Also, government and third-party payers are going to assign severity and risk scores based on the diagnosis codes billed, and these scores will help you justify higher level codes and better reimbursement in the future.  Start now to assign the accurate ICD-9-CM code for the documentation that you provide and you can make a step for easier transition on October 1, 2014. 



ICD-10 Revenue Neutrality: Where is Your Organization?

The transition to ICD-10 on October 1, 2014 will have a profound impact on the healthcare industry.  The benefits of such a transition are many; to include improved clinical reporting and potential increased revenue generation as submitted claims data will be far more specific than what is generated today.  As an industry, there has been a huge emphasis on physician documentation and coder education to ensure that the appropriate ICD-10 code is selected, populated in the electronic medical record and billed.  Plans are in place to begin the process of “dual coding” in an effort to proactively address the trouble spots; orthopedics and cardiology immediately coming to mind given the bilateral nature of limbs and arteries.  IT systems are being evaluated to ensure that any reference to ICD-9 is programmed to support ICD-10 nomenclature and payer contracts are being reviewed to ensure that any contract language related to ICD-9 is replaced with ICD-10.

The above initiatives are critical as you make your preparations for ICD-10.  But what about your revenue cycle?  Have you considered the concept of “Revenue Neutrality” as you march toward the compliance date for ICD-10?   What are you doing to prepare for the potential increases in claims edits, payer denials, and accounts receivable?  Batten down the hatches.  The ICD-10 tsunami wave is coming.  How significantly the wave will affect your organization is not yet known but the prediction based on a study published by WEDI (Workgroup for Electronic Data Interchange) is that your accounts receivable may increase by 20% – 40% and your denials may increase 100% – 200%! 

In an effort to minimize the impact of ICD-10 on your revenue cycle operation, immediately begin to assess your current processes from the beginning of the revenue cycle to the end.  Many organizations place their focus on the coding team and fail to assess other critical revenue cycle functions that may be impacted.  Flowchart your work flows to identify all areas where diagnosis coding is required.  If you have pain points now they will undoubtedly be exacerbated with ICD-10.

The following list identifies just a few of the Revenue Cycle areas that you need to consider:

  • Will all of your IT systems and any vendor systems utilized be updated from ICD-9 to ICD-10?
  • Are ICD codes required during your registration or scheduling process? 
  • Will your scheduling and registration systems accommodate the extended length of the ICD-10 code?
  • Will your medical necessity process accommodate the length of the ICD10 code?
  • Will there be any prior authorization concerns?
  • Will your physicians be able to order ancillary tests by providing the proper ICD-10 code?
  • Will your claims scrubber vendor be fully compliant and able to test ICD-10 claims months prior to the implementation?
  • What is your current denial rate?  Do you understand the root cause of these denials?  Pay close attention to denials related to Medical Necessity as these types of denials are bound to be impacted by the ICD-10 implementation.
  • Focus on improving all key performance metrics now.  Close and bill encounters in a timely fashion.  Reduce your claims edit rate and work your accounts receivable to ensure that you are able to manage any increases that occur upon implementation.
  • Develop dashboards to measure these metrics now and post ICD-10 to ensure you are reaching your revenue neutrality goals.
  • Document your ICD9 to ICD10 boundary Cutover Concerns and develop plans to address them.

In summary, the transition to ICD-10 will affect just about every facet of your organization.  As with any major change, developing a plan that includes revenue cycle preparedness is the key to realizing the benefits of the implementation in years to come.

 Reference from Workgroup for Electronic Data Exchange White paper Impact Assessment


Optimizing Clinical Documentation

Optimizing Clinical Documentation
Now Is the Time to Get Started

Many healthcare organizations capture clinical documentation via electronic health records (EHRs) and other technology-enabled channels. The ability to fully leverage clinical documentation to improve care, compliance and reimbursement depends on its quality. In my experience, engaging in clinical documentation optimization is a valuable exercise that can yield tangible benefits.

The October 1, 2014 ICD-10 deadline is probably the most compelling reason to focus on optimizing documentation right now. ICD-10 requires a high degree of specificity, and if your documentation doesn’t have it, you could see a drop in reimbursement and/or an increase in claims denials. On the other hand, if your documentation is detailed and reflects a true picture of the patient experience, coders can more accurately code claims, ensuring you receive full reimbursement for services rendered.

While a significant impetus for improvement, ICD-10 compliance isn’t the only driver for optimization. By striving for more detail and accuracy in clinical documentation, your organization can elevate care quality through better communication among providers. Strong documentation ensures everyone who interacts with the patient is on the same page about diagnosis, treatment and patient response. Embedding care alerts and reminders for patients in documentation can further enhance quality.

Comprehensive documentation also ensures you use technology—electronic health records, for example—to its full potential, which can drive physician productivity as well as adoption.

Thorough documentation can also enhance reporting, which in turn, supports better care delivery. Discreet levels of data are necessary to generate accurate quality reports.

Finally, better documentation fosters more timely claims submission, which results in improved cash flow and reimbursement and leads to fewer denials, ultimately preserving your revenue cycle integrity.

Acknowledging the importance of enriching clinical documentation is the first step toward optimization. To make meaningful progress, I suggest organizations consider and customize the following high-level next steps:

1. Establish goals. Be specific about objectives, timelines, training and who will do the work to drive and manage the improvement process and subsequent changes.

2. Determine early focus. High-volume, high-reimbursement clinical areas and processes make a logical place to start work. In my experience, strengthening documentation in these areas can prevent substantial hits to cash flow and revenue.

3. Examine specialties. Concentrate on those areas that have the most significant changes in documentation requirements, such as cardiology and orthopedics. The physicians in these areas will need to significantly “up their game” when it comes to documentation and can provide valuable input for system workflow retooling.

4. Identify areas of “quick wins.” Give special attention to areas of strong physician support because physician champions can serve as positive role models for adoption in other areas. Identify key players within specialties and promote their demonstrated success to break down change management challenges in other areas.

While ICD-10 makes optimizing clinical documentation a top priority now, improvement work in this area should be an ongoing process with the ultimate goal of elevating clinical care. Organizations that commit to a continuous effort to enhance detail, accuracy and consistency, can see real benefits in terms of both revenue and patient care. Although the idea of revamping clinical documentation may seem daunting, organizations can see big improvements with small changes. The key is acknowledging the importance of the work and getting started on the journey; in my mind, there is no time like the present.

Brad Boyd


ICD-10 Impact on Revenue Cycle & Clinical Workflows-Webinar 12-13-13 12:30 EST

Angela Hickman pic


 Join our Webinar

Join Angela Hickman, CPC, CEDC, AHIMA ICD-10-CM/PCS Certified Trainer, AHIMA Ambassador, and senior consultant at Culbert Healthcare Solutions on Friday, December 13th at 12:30 pm Eastern for an insightful look into the impact of ICD-10 on revenue cycle operations and clinical workflows as she shares her knowledge on how to successfully navigate the complexities of an ICD-10 conversion.

 This one hour online webinar will discuss and demonstrate the following processes:

  •  Physician documentation process
  • Clinical data reporting
  • Pre-registration
  • Coding, CDI and billing workflow
  • Claims adjudication & resubmission process

Date: Friday, December 13, 2013

Time: 12:30 – 1:30 EST