Posted in ICD-10 & Coding

Why small practices may be struggling after ICD-10 grace period

Carl Natale
by Carl Natale
Why small practices may be struggling after ICD-10 grace period

There's no evidence that small medical practices and independent physicians are having problems since the grace period on ICD-10 specificity ended Oct. 1.

Since it the only applied to Medicare fee-for-service claims from physicians billed under the Medicare Fee-for-Service Part B physician fee schedule, the impact should be limited.

But Debi Primeau, president of Primeau Consulting Group, told Health Data Management that smaller physician groups and medical practices were more likely to use unspecified ICD-10 codes instead of more specific and accurate ICD-10 codes.

There's no evidence that is true though.

Even so, it's not a bad idea to take Primeau's advice and audit the mix of ICD-10 codes to see how specific ICD-10 coding was in the first year.  That could lead to an increase in reimbursements and a denial prevention strategy.

Earlier this year, Primeau reviewed eight potential denial data points:

  • Sequencing: Review the ICD-10-CM guidelines to make sure right ICD-10 codes are chosen for the primary diagnosis.
  • Aftercare: The Z codes designate specific instances of aftercare. But usually it is correct to use the injury ICD-10 code with the seventh character designating a subsequent encounter.
  • Unspecified codes: Yes, they do exist. But will auditors start looking for them?
  • Laterality: It's great that ICD-10 codes allow to differentiate between the left and right sides of the body. But sometimes one bilateral code is needed instead of two diagnosis codes to designate the left and right side as affected.
  • Hip and knee replacements: Use ICD-10-PCS codes for removal and replacement.
  • Missing codes: This may get some physician push back. But the guidelines require supporting diagnoses in some cases.
  • Medical necessity: This is going to require keeping up with local coverage determination (LCD) and national coverage determination (NCD) updates.

This is the kind of data that healthcare payers have been analyzing that might drive denial decisions. Medical practices should use their data to find any problems first.