ICD-10 Implementation

By Adrienne Dresevic, Esq., and Leslie A. Rojas, Esq., of The Health Law Partners, P.C. 

The ICD-10 implementation date is right around the corner. Claims with a date of service on or after October 1, 2015, must use the ICD-10 coding system or the claim will be denied. Radiology departments will be impacted by the transition in ways that other departments and physicians may not be. Radiologists rely on information provided by referring physicians to meet their own documentation requirements. Detailed information from the referring physician regarding the patient’s diagnosis and the reason for the testing is essential to meet the radiologist’s documentation requirements. This information is often missing or lacking in specificity, which is one of the main reasons that claims are denied for not being “medically necessary.”

Lack of proper specificity in referring physician documentation was an issue under ICD-9. However, the requirements under ICD-10 are even more comprehensive. Referring physicians must provide more detail in their diagnoses and reasoning for the tests so that radiologists can prepare reports that meet ICD-10 documentation requirements. For example, referring physicians will be required to provide more details on certain elements of the patient’s condition, such as laterality, anatomic locality, severity, related causes of the pain/condition, related signs/symptoms, combination codes, and whether the encounter is an initial (active treatment of injury/condition), subsequent (post-active treatment of injury/condition), or sequela encounter (complications or conditions suffered from injury/condition).

Ideally, radiology departments would have prepared for the October 1, 2015, transition well in advance of the implementation date. That preparation should have involved coding staff closely comparing the ICD-9 to ICD-10 conversion crosswalk. This is critical because the number of diagnosis codes associated with ICD-10 equal just over 140,000 – as compared to approximately 18,000 codes associated with ICD-9. In many cases, a particular ICD-9 code was converted to 10 or more ICD-10 codes to choose from.

Acknowledging that the transition will not be easy, Medicare announced that, during the first 12 months of ICD-10 implementation, Medicare will not deny claims with incorrect ICD-10 codes if the code is from the correct family of codes (see Medicare guidance available here). However, this leeway does not apply if there has been a National Coverage Determination (NCD) or Local Coverage Determination (LCD) issued for the particular test or procedure which specifies the appropriate diagnosis codes to be used. In this case, Medicare will reject the claim – even if the code used is within the proper family.

In preparation for October 1^st, radiology departments should:

• Have coding staff review and become familiar with ICD-9 and ICD-10 conversion crosswalks
• Have coding staff review NCDs and LCDs issued for the tests and procedures performed in the department
• Implement appropriate procedures for the patient scheduling and registration process to ensure that they obtain the clinical history necessary for the heightened ICD-10 documentation standards
• Work with referring physicians to ensure that they are prepared to provide detailed diagnoses and reasons for the test. Electronic medical record systems and computer-assisted coding systems can help with this process
• Conduct billing audits to determine whether the department’s procedures have resulted in proper ICD-10 coding and to determine what improvements are necessary
• Conduct staff training on clinical documentation and coding issues. Departments should not only train its coding staff and radiologists, but also staff involved in the patient pre-authorization, registration, and intake processes

Even in these final few weeks, preparation for the ICD-10 implementation date and continued monitoring of the department’s coding procedures are critical. Lack of preparation and continued monitoring may result in a significant decline in revenue. Resources to help with the transition may be found on CMS’s website here.

Adrienne Dresevic, Esq. graduated Magna Cum Laude from Wayne State University Law School. Practicing healthcare law, she concentrates in Stark and fraud/abuse, representing various diagnostic imaging providers, e.g., IDTFs, mobile leasing entities, and radiology and multi-specialty group practices.

Leslie Rojas, Esq. graduated from Wayne State University Law School and is licensed to practice law in Michigan and Illinois. Practicing healthcare law, she concentrates on fraud/abuse issues, compliance with federal and state healthcare regulations, health information privacy and technology issues, and transactional and corporate aspects of healthcare.

The authors are members of The Health Law Partners, P.C. and may be reached at (248) 996-8510 or (212) 734-0128, or at www.thehlp.com.

For more regulatory news, visit www.ahraonline.org/news.