With the October 1, 2015, implementation of ICD-10 around the corner, Pamela Bensen, MD, MS, FACEP, is warning physicians to get all billing out by the end of September.
“The earlier you get it out, the better the chances you can get paid for what’s been done already before we run into the morass of ICD-10,” said Dr. Bensen, an emergency physician and clinical documentation improvement consultant.
On July 6, 2015, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) announced a transition period to help ease the switch from ICD-9 to ICD-10. According to AMA President Steven Stack, MD, FACEP, an emergency physician and ACEP member, the agreement is intended to “ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs.”
But Dr. Bensen, a self-described optimist, is concerned. She said CMS does not provide enough detail about the transition to assure her that physicians and hospitals won’t find themselves in serious trouble come fall. Dr. Bensen is advising physicians to take a 12-month credit line to cover their expenses. CMS is predicting a 140 percent increase in denials, she said, and she expects it to be much higher.
For instance, for one year following the October 1, 2015, implementation, CMS said that while a valid ICD-10 code will be required on all claims, Medicare review contractors will not deny claims based on lack of specificity so long as codes from within the right family are used, nor will CMS penalize physicians under the Physician Quality Reporting System for the same.
“We don’t know what a family is, and it’s not defined in ICD-10, and it’s not defined on the CMS website,” said Dr. Bensen, who is also an ICD-10 specialist who teaches documentation to clinicians. “It’s just not terminology we use, and does that mean—there are almost 400 diabetes codes in ICD-10—I can use any of them and I’m OK?”
Also at issue, she said, are advance payments. CMS says advance payments “may be available” if contractors cannot process claims “within established time limits because of administrative problems” and will base this on “historical data.”
“But there is no historical data for ICD-10,” Dr. Bensen said. She has submitted a long list of questions to Dr. Stack, seeking clarification, and she will follow up with senators and representative if she does not receive answers. Dr. Bensen has proposed a more gradual phase in to ICD-10.
To be better prepared, physicians, she said, need to boost their documentation. “Instead of a list of diagnoses, you would have a sentence: Acute systolic heart failure due to hypertensive heart disease with chronic kidney disease, stage 5,” she said. She also suggests physicians leave coding up to their coding specialists, to remain focused on documentation.
Given her experience – several hospitals have recently hired her to work with their physicians – Dr. Bensen said providers simply aren’t prepared, particularly since some saw the yearlong delay as a sign ICD-10 wasn’t going to happen at all.
“I’m not confident at all that this transition is a true transition,” Dr. Bensen said. “I don’t think CMS has any clue how unprepared [physicians] are.”