Oct. 1, 2014, is an example of how one cog in the revenue cycle can impact the entire wheel. Some are already referring to ICD-10 as the healthcare industry’s version of Y2K.
In the context of the revenue cycle, ICD-9 to ICD-10 shows that reimbursement isn’t solely the responsibility of the accounts receivable. While healthcare organizations need to engage their payers to ensure a smooth transition, they must similarly engage their physicians and coders in knowing how valuable their roles are in ensuring that bills get paid.
On the one hand, ICD-10 requires clear communication with payers. This is where conversations about general equivalency mappings (GEMs) and diagnosis-related groups (DRG) become essential for healthcare organizations.
“We truly believe it’s going to be a problematic area if hospitals do not engage and understand how they are going to map and pay them under the DRG model,” says HRAA CEO and Chairman Andrea Clark. “If they do not engage in that conversation and October 2nd, 3rd, 4th, or 5th of 2014 comes along, they can be surprised at the amount of denials they may receive along with suspension of claims and not have a strategy in place to correct those problems.”
Unless a health system, hospital, or physician practice understands how their payers will handle their claims, they will not be translate their submissions into the appropriate (i.e., acceptable) format. “They need to be able to translate from ICD-9 to ICD-10 utilizing the GEMs and be able to take a look at if a payer is going to group and use a grouper in ICD-10 or are they going to take the ICD-10 codes and group them back to an ICD-9 DRG grouper,” adds Clark.
On the other hand, ICD-10 is about what happens in the clinical environment. This is where documentation enters into the equation. Members of staff must know the role they play in the coding process. Considering the number of codes in play in ICD-10, clinical staff can easily become overwhelmed. However, a measured approach could help them build familiarity with ICD-10 codes.
“Start looking at your practice, what you do and see, and then think about how ICD-10 will affect that,” says Lou Ann Widemann, MS, RHIA, FHIMA, CDIP, CPEHR, Director of Practice Excellence at AHIMA. “Don’t try to do it all. Try to focus on the majority of the patients you see. If you’re an orthopedic surgeon, then focus on those changes. If you’re a pediatrician and you see a lot of asthma, focus on that. It’s all about focus. From a physician’s standpoint, if 50 percent of your patients have asthma, then I would focus on that.”
As the effort to improve clinical documentation reveals, how physicians and other clinicians document their care is a work in process. “Documentation is not taught in medical school — nobody teaches anybody how to document — so this whole process and concept of painting the accurate picture is kind of new. You would think that it’s been around for years, but it really hasn’t. The focus on it has changed,” observes Widemann.
ICD-10 will be a serious test for the healthcare industry. For the revenue cycle, those who come out on top will be those who are mindful of each department’s role in keeping that revenue wheel spinning.