Why ICD-10 Coding Demands a Focused Compliance Perspective

November 13, 2015 - Now that mid-November is here, healthcare entities should be prepared to respond to aggressive audits and clinical documentation enforcement efforts regarding ICD-10 code selections, or will face fraudulent billing claims.

Such stated George B. Breen, Member of Epstein Becker & Green (EBG) Firm in the Health Care and Life Sciences and Litigation Practices, Chair of the National Health Care and Life Sciences Practice Steering Committee, and a Board of Directors member, in a recent dual interview with RevCycleIntelligence.com, published merely hours before ICD-10 implementation went live.

Now with six weeks of ICD-10 implementation underway, Breen spoke with Xtelligent Media once again to reassess how and why healthcare entities should continuously evaluate their payment and audit objectives regarding coding inconsistencies.

RevCycleIntelligence.com: How did ICD-10 implementation unfold thus far compared to initial expectation? What can the healthcare industry expect going into 2016?

George Breen: People thought so long as they were able to get through week one there would be some comfort about being able to go forward on a grander scale. My reaction to that was, "You're not going to be able to assess this realistically after week one, and don't allow yourself to get into a false sense of security that things are okay just because you have."

At year-end, maybe you’ll see some reflection of changes, as RevCycleIntelligence.com reported late last week, on CMS's announcement that was touting some success in terms of the transition. Let's face it, there were pretty lengthy delays to the implementation of ICD-10. Frankly, the delays helped the process in terms of having people be better prepared.

For year-end, I'm not sure we have an accurate picture of what really is going on relative to the revenue impact. The 12-month grace period for physicians, other practitioner part D claims, doesn't really help in terms of assessing what the overall revenue impact is going to be because you have to live through that a bit. 

We'll see different reactions as if we're talking about commercial carriers and providers dealing with commercial carrier payments, but we have a bit of time to go before we can really see where this is ultimately heading.

RevCycleIntelligence.com: With these types of unknowns currently unfolding, how focused should healthcare providers be on compliance issues at this stage in the ICD-10 game?

GB: The impact of ICD-10 needs to be looked at from a compliance perspective, from a perspective of where the government will be looking now that ICD-10 is here. There ought to be a focus on making sure that the documentation is as detailed as will be accepted to justify the ICD-10 coding.

We don't know yet how and to what extent private payers are going to elect to look at medical records, compare them with selected ICD-10 codes, and determine whether or not there's accuracy or inaccuracy there and what interpretation they will have if they find inaccuracies.

While I can appreciate that there are coding challenges and revenue challenges, what shouldn't get lost here is the notion that from a compliance perspective, you need to be making sure the medical documentation is at a level which justifies and supports the coding. You need to be looking for issues as they are arising and correcting them.

People should not lose sight of the fact that there are real compliance issues going on here. In particular, you've got the 12-month grace period for a practitioner and other part D claims. The opportunity is there for the compliance department to make sure they're fully invested in testing this and making sure missed areas are being corrected.

The compliance department needs to make sure that looking at ICD-10 is part of their internal audit process. You need a process in place which addresses the issues of appropriate coding and makes sure that the documentation supports the code.

It's not only making sure the revenue folks are set up and working appropriately, it also means you have to make sure your practitioners are set up and working appropriately and there's an understanding by both your revenue people and your billing professionals about expectations.

This 12-month period allows, at least as it relates to certain claims, is an opportunity for compliance to engage in that kind of activity, as it really should.

RevCycleIntelligence.com: There has been some speculation that some may not be taking ICD-10 implementation as seriously as they perhaps should, only putting themselves at risk for audit. What are your thoughts?

GB: The issues of medical necessity and reasonableness are hot issues for the government. Anything that allows the government to come in and take a closer look at your claims and your records ought to be things you take very seriously.

There needs to be a recognition that both public and private payers are looking at these issues very seriously, and certainly at this point no one could come and say, "Well, here's the investigation about ICD-10 that ought to tell you this is why it's serious." Those haven't happened yet. It's too soon.

But, when you look at the level of specificity that the codes call for and expectations related to the supporting medical record documentation, it is another reminder for providers to ensure they're supporting the billing that they have support for the billing that they're submitting.

The reality is most people are billing and coding and documenting in a fashion they believe absolutely justifies the bills. It’s another reminder for people to consider that this is an area the government has been looking at for a long time, it's laser focused on these issues. This gives the government another opportunity to examine these issues, which is why it ought to be significant.