For hospitals and physician groups a critical period is arriving on October 1, 2016. Medicare’s one-year of claims payment review leniency is ending. During Medicare’s one-year’s Flexibility, guidance was provided to Medicare contractors to allow payment for services if the provider used a valid ICD-10 code. Claims would not be rejected if diagnoses were not coded to the highest level of specificity allowed for in ICD-10 coding. In other words, the contractors were instructed to not consider the specificity of the diagnosis but only to make sure that the diagnosis reported was valid.

Come October 1, 2016 the year of claim leniency is ending. Payers will now be reviewing ICD-10 coding for specificity and claims may be bounced back for “diagnoses lacking specificity”.

No longer will “unspecified” codes be accepted when the clinical documentation (if done correctly) supports a more detailed ICD-10 code.

There is a price to be paid for the forgiveness of omission that CMS allowed in this past year but that is over. The real challenge is ahead regarding both specificity of Coding and specificity of clinical documentation. Physicians will have to start including terminology that refers to laterality; for example, in order for the ICD-10 code to be assigned to the fullest level of specificity.

Changing of documentation habits should be of utmost concern to hospitals and physician groups alike because physician documentation patterns will be difficult to break.

On the physician side there isn’t much incentive to begin a process of very detailed and specific documentation about site, size etc.

Many of our clients have told us of the hours spent in training of staff, but now is the time to involve the Medical staff in a meaningful way to be part of the solution. For some clients, we have recommended a “deconstruction of encounters and cases done within the last fiscal year. This is done in order to determine by clinical discipline how far off or on each has been on both the clinical documentation and coding. We have helped some of our clients to set up work teams made up of the Coder/biller team to reconstruct cases in terms of what they must look like in order to have clean claims and reimbursement.

The first step is to look at the data and diagnoses by discipline and analyze for cases that would not meet this year’s requirements (as announced and promulgated last year). The next step is to pick a sample and have the respective disciplines with Coding staff assigned to the discipline to go over each case for ultimate presentation as part of an in service or grand rounds for each discipline.

The medical staff think in clinical terms with broader brushstrokes and need to understand we are painting the trim with the extra specificity.

For 30 years Health Systems Management has been providing such services to many of the country’s outstanding Medical Centers and smaller community hospitals/physician groups.

Please contact us to discuss a plan that can be implemented immediately starting with a data and medical record review.