Electronic Health Records

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ICD-10 might be even tougher for non-HIPAA entities

By Jennifer Bresnick

- Think you’ve got it rough with ICD-10?  You may be thankful that you’re not a non-HIPAA covered entity working in the auto collision or worker’s compensation field.  Being exempt from the federal mandate to move to ICD-10 by October 1, 2014 might seem like a good thing at first blush, but it’s going to cause a lot of headaches for an industry that now has to contend with a new coding standard in addition to ICD-9 when accepting claims that still come in as a mix of paper and electronic bills.

“We want to make sure that we’re covered, just like everybody else,” explains Michele Hibbert-Iacobacci, Vice President of Information and Support at Mitchell International, which provides claims management software solutions to payers in the auto and worker’s compensation industry.  “Up to this point, everyone has been interested in the value that ICD-10 can provide in the performance of bill review and making payments.  But I think the big concern these days is less about the payers and more about the providers when it comes to their readiness and whether or not they’re going bill everybody the same.”

“It should be noted that that a number of these providers only play in the casualty space, and they’re used to submitting paper bills and not moving into the electronic world,” she continued.  “So we always have to consider the paper processes, too, unless the state passes legislation that says everyone needs to do everything electronically like Medicare does.  Short of putting your bill on a banana peel, the payers in casualty have to take what is written by the provider and submit it, some without standards, not even ICD-9.  That’s been the case all along.”

“We also thought about a lot of the ‘over-coding’ we see on the bills we get.  This is how the providers communicate with their payers, so they may try even to duplicate using ICD-9 and ICD-10 on the same bills, just to make sure that the payer has everything they need to pay the claim,” she added.  “That makes for big challenges for payers when they’re going to get all kinds of things coming in the door.”

Suddenly, standards aren’t looking all that bad.  And while providers on the medical side have long complained about the increased detail and specificity involved with the ICD-10 code set, Hibbert-Iacobacci believes that they may be a very good thing for auto claims, despite the challenges. “ICD-10 brings with it the possibility that, especially in the area of sprains and strains, providers will use the most severe code instead of using one that may be more appropriate, in order to get paid,” she says.

“If you’re offered the use of multiple codes to code a cervical sprain, and there are three different ones you can choose from, dealing with muscle, ligament, fascia, bone, we’re thinking that they’re either going to use all of them, or they may choose the one that is the most severe for their particular case.  In that way, it will cause, perhaps, some more investigation by the claim representative to read the documentation.”

“But there’s some value that it does bring,” she is quick to point out.  “It gives you a more complete description of actually what’s being done.  For automobile accident claims, it really is important to know if it’s the right or the left side of the body, because that can indicate where they’re sitting in the car and the accident impact.  ICD-10 brings us that knowledge, and that’s really important.  When we’re adjusting claims, sometimes we have to ask, even after the bill comes in, if it’s the right or the left side.  Constantly.”

“The encounter codes will also be important.  If it’s the first time someone’s been treated, if it’s a sequelae, or if it’s basically just a follow-up: those three things will help an adjuster evaluate if a certain condition is related to the auto accident in question, or if it was exacerbated by the incident, or if it was totally unrelated.  In the new healthcare payer world that we have right now, preexisting conditions are pretty much thrown out the window.  But with auto, that matters because you’re paying a policy for a specific incident, not things that happened before.”

While the encounter codes and specific details may be helpful for payers looking closely at a single episode, they have been problematic for providers who are not used to including that level of detail in their clinical documentation.  But this isn’t the first time the healthcare industry has been asked to make a major shift to a new way of coding and documenting encounters, Hibbert-Iacobacci reminds providers.

“There aren’t a whole lot of people around that were around when ICD-9 became a standard, but I was working in an acute care facility when we moved to ICD-9 from ICD-8 and HICDA, which was a hospital adaptation,” Hibbert-Iacobacci recalls.  “Those two coding systems were used across the country, but they weren’t used consistently.  ICD-8 was used in some; HICDA was used in others.  ICD-9 was supposed to be the very first implementation across the country as a standard.”

“So this is really the second time I’m going through this. But we’re more in the electronic world now, and that has really been considered during the discussions about implementing ICD-10.  It wasn’t easy the first time, but it didn’t take very long for everyone to catch on.  I would say probably two to three years.”

Most providers don’t have the luxury of slowly acclimating to the new codes, however, since revenue cycles depend on a quick turnaround for claims that need to be paid.  As the ICD-10 deadline approaches and stakeholders across the board scramble to make the grade, providers might want to take the opportunity to be glad that the majority of large health plans have already made preparations to switch to the new codes, a task that has been difficult enough on its own without worrying about what else might make its way through the mail.

 

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