December, 2015:

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.

ICD-10 Two Months In: How the Transition has Impacted the Industry

Culbert Healthcare Solutions Scott Griffin- VP of Consulting Services gives an inside look – HCI -Healthcare Informatics

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The Fine Line Between Implementation & Optimization

It’s quite rewarding to work with clients who are in the middle of long, complex EMR and Business Application implementations who have a strong desire to utilize their new tool to its fullest potential.  With that said, the old saying “walk before you run” comes to mind.  One might argue that it is best practice to learn the fundamental basics of a new technology solution rather than dive into the deep end of the pool by building highly complex workflows that are customized to various constituents within your organization.

This is especially true for the Health System that is involved in a prolonged transition, migrating hospitals and physician practices over the course of multiple years.  The physicians, nursing staff and revenue cycle staff that were involved in the initial phase of the implementation have become “seasoned” users and feel they are ready for a more sophisticated technology experience.  Those who have transitioned thirty days ago need time to get to know the tool, its basic capabilities and functions.

What does an organization in this situation do?  Do enhancements that affect the system as a whole get introduced now to elevate performance for those who have been using the new system for more than a year?  Do you potentially frustrate the experienced user while the remaining Health System rolls out the new technology system-wide knowing that it may be two years to complete?  Do you have the resources to dedicate to enhancements while you are in an implementation mode?

These decisions require a strong governance structure with comprehensive representation from all facets of the organization that is affected by the new technology.  Discussions need to take place to determine if an enhancement is in the best interest for all end users whether they are novices or experts in the system.  If the decision to enhance the system during implementation is made, a robust process for training providers and staff on the new functionality must be developed.  Effective communication campaigns and end user system support should also be provided.

It can become a very fine line between a “must have” and a “nice to have”.  Strong guiding principles related to technology changes during implementation will be key to navigating the myriad of requests that will be made.


MIR_3944-Johanna Epstein