There is a dangerous myth that has worked its way into the psyches of medical coders and planning committees in the midst of preparing for ICD-10. “ICD-10 won’t affect my outpatient services. My CPT codes are all I need,” it says, lulling professionals into a false sense of security.
While it’s true that CPT/HCPCS codes will continue to be the gold standard for outpatient procedures, providers will be required to include ICD-10 diagnostic codes with their claims in order to receive reimbursements from payers. With outpatient procedures making up an average of a third of a hospital’s revenue, it’s important not to dismiss the effect that ICD-10 will have on outpatient operations.
ICD-10 is divided into two components: the ICD-10-CM diagnostic codes, and the ICD-10-PCS procedure codes. ICD-10-CM is the newest iteration of diagnostic codes, and will replace ICD-9 codes entirely. ICD-10-PCS will be used exclusively to code procedures provided for inpatient services, while the majority of payers will continue to accept the most current edition of CPT codes for outpatient procedure claims. Payers will use the ICD-10-CM diagnostic codes to judge the validity of a procedure in order to reduce false or inflated reimbursement claims.
“If you ask an organization about who does outpatient diagnosis coding at their facility and you’ll typically find there are lots of departments and fingers involved,” says a blogger for Santa Rosa Consulting, which conducts impact assessments for the ICD-10 transition. “Worse, they often can’t tell you specifically who does the coding or how coding is accomplished for all of the types of outpatient visits to the facility.” Developing a clear idea of who will be responsible for outpatient ICD-10 coding is the first step towards ensuring that the proper staff members will receive training and education.
Ignoring this oft-overlooked area may have substantial consequences. Providers who do not provide adequate diagnostic justification for a claim risk having those claims denied. Improperly coded claims expose organizations to Medicare audits, which can cost providers a significant sum in retracted reimbursements.
Everyone involved in coding in any capacity should be identified and provided with an ICD-10 training course suited to his or her role. Be sure that ICD-10 transition leaders are aware of the differences between ICD-10-CM and ICD-10-PCS to avoid reimbursement complications that could interrupt revenue flow during this critical time.