Despite years of preparation, patient access departments can expect to encounter problems involving the switch to ICD-10. These problems include orders with ICD-9 codes, delays in scheduling or registration, and increases in claims denials. To avoid problems, do the following:
Educate providers if incorrect coding is used.
Create “cheat sheets” covering the top diagnoses at each registration area.
Closely track registration times and claims denials.
Patient access departments had extra time to prepare for the switch to ICD-10, due to the original compliance date being pushed back to Oct. 1, 2015. Now it’s the moment of truth, and the possibility of productivity or revenue cycle problems are at the top of managers’ minds.
“So far, the sky hasn’t fallen when it comes to ICD-10,” says David Kelly, director of revenue cycle at Mary Rutan Hospital in Bellefontaine, OH. The department’s “cheat sheets” are helping staff to deal with older, handwritten ICD-9 orders.
“We are seeing some sporadic technical glitches in our systems that we are working through, but no significant delays within the patient access realm,” reports Kelly.
The hospital’s health information management department is seeing some slowdowns. “We haven’t really gotten through enough of a cycle for me to weigh in on the impact in the patient financial services and billing areas yet,” says Kelly.
Mansi Patel, MPH, manager of patient access quality assurance and training at Children’s Healthcare of Atlanta, says, “Thus far, there have not been hiccups. From an authorization standpoint, all is going well.”
Jim Daley, co-chair of the Workgroup for Electronic Data Interchange’s ICD-10, says that if problems do occur in patient access, “have channels in place for immediate action. Know who to call if an issue comes up.” Daley is also director of IT at BlueCross BlueShield of South Carolina in Columbia.
Here are some ICD-10 issues that patient access should watch for:
• Increased numbers of claims denials because software didn’t get updated correctly.
Are some of the systems used by patient access not fully updated to require ICD-10 codes? If not, “because patient access very often handles medical necessity checking, that is one area which will potentially result in a significant number of denials,” warns Sandra J. Wolfskill, FHFMA, director of healthcare finance policy at the Healthcare Finance Management Association.
Patient access managers at Albany (NY) Medical Center ran reports throughout September 2015, to ensure all encounters scheduled for 10/1 and beyond had ICD-10 codes. Still, “there were some scheduled encounters on 10/1 that still had ICD-9 codes that had to be revised,” reports Brenda Pascarella, CHAM, associate director of patient access. Also, charges from an offsite non-patient lab included an ICD-9 code.
“IT is working to correct this,” says Pascarella. “We also worked with IT to ensure all treatment series had a 10/1 encounter and all older treatment series were closed.”
At Children’s Healthcare of Atlanta, patient access leaders built a rule into the hospital’s Epic system to identify ICD-9 codes listed in the diagnosis field on the authorization or referral. “It will appear as a warning message in the missing information registration and verification work queue, informing the end user to update the diagnosis to an ICD-10 code,” says Patel. (See answers to actual questions submitted by the department’s patient access employees about ICD-10, in this issue.)
• Patient dissatisfaction due to delays caused by the need to validate orders.
“Potential delays are the biggest challenge with ICD-10,” says Kelly. “Patients won’t necessarily be understanding of the reason behind the delay.”
Interpretation of orders will become more complicated for patient access staff. “The need to contact referring providers for clarification of orders, particularly for walk-in patients, will likely be the biggest impact on throughput,” predicts Kelly.
If physicians continue to provide codes in ICD-9, patient access staff won’t be able to properly code the order in the order entry system. Wolfskill says, “This may result in incorrect or denied payment.”
Anytime an order cannot be mapped from one code to another, or from a narrative code to a numeric code, the diagnosing provider must be the one to clarify the order, notes Kelly. “Scripting, signage, and cross-walks for codes are likely to be the best possible mitigations,” he suggests. “But it isn’t possible to totally remove the risk of delay.”
Patient access should use each contact with providers as a “teachable moment” to improve specificity of orders, says Kelly. “Now more than ever, communication with your referring providers is critical,” he says. “Often, the best communication is face to face.”
If orders are incorrectly coded, services might need to be rescheduled because authorizations can’t be obtained. “If a hospital has moderate or aggressive pre-service collection practices, more may fall to the patient than is necessary, who may then opt to reschedule,” explains Kelly. He recommends that patient access leaders meet jointly with Health Information Management and scheduling teams. “Have the best ‘cheat sheets’ you possibly can,” he says. “They should cover the top 20 to 30 diagnoses seen at each physical access point of care.”
The department created lists of the top diagnoses, organized by the physical walk-in location. If an order maps to multiple codes, patient access calls the referral source for clarification. “We arrived at our mapping by using two software tools and then having our ICD-10 certified coding coordinator review,” says Kelly. [The Top Diagnoses by Access Point electronic form used by the department is included with the online issue. For assistance accessing your online issue, contact customer service at [email protected] or (800) 688-2421.]
• Possible changes in coverage determination.
Daley says, “This might occur if the payer has changed medical policies to take advantage of the granularity of ICD-10. While a general benefit might be present, there may be special carveouts based on the specific coverage plan.”
He gives the example of a liver transplant, which previously had a single code for complications. Now there are multiple codes, including failure due to infection. If this code is used, it could result in an authorization being denied or delayed if the payer wants to explore whether the infection was due to a hospital-acquired infection.
However, Daley doesn’t expect to see widespread claims denials, at least not in the short term, due to the increased specificity of coding. “Most payers I’ve talked to say, ‘We’re not trying to change coverage and benefits,’” he says. “For the most part, they’re trying to keep things as smooth as possible, with minimal change and disruption.”
Albany Medical Center’s patient access leaders researched how each payer was handling authorizations after Oct. 1 and also admissions for services dates crossing from Sept. 29 into Oct. 1. “We’ll be watching for any denied claims and working to resubmit with accurate information, whether this means ICD-10 codes or proper authorization or notification,” says Pascarella.
• Longer wait times for registration.
Patient access “will need to know more than they used to,” says Daley. For example, registrars now need more details about how an injury occurred. Collection of this additional data might mean registration takes longer to complete. “This might not show up in the first day or two, but certainly as time goes on, some delays may occur,” says Daley.
Registrars might need to make more phone calls to obtain authorizations.
“In some cases, patient access may find that electronic eligibility doesn’t quite cut it under ICD-10,” explains Daley. “More information may be needed.”
Jim Daley, BlueCross BlueShield of South Carolina, Columbia. Email: [email protected].
David Kelly, Mary Rutan Hospital, Bellefontaine, OH. Phone: (937) 651-6338. Email: [email protected].
Brenda Pascarella, CHAM, Albany (NY) Medical Center. Phone: (518) 262-4559. Email: [email protected].
Mansi Patel, MPH, Children’s Healthcare of Atlanta. Email: [email protected].
Sandra J. Wolfskill, FHFMA, Healthcare Finance Management Association, Westchester, IL. Phone: (708) 531-9600. Email: [email protected].