Getting a Handle on Denials in the Post-ICD-10 World

webinar
Getting a Handle on Denials in the Post
ICD-10 World
Presented by Betsy Nicoletti October 22, 2015

@GoKareo
Agenda
2
Agenda
2
• Welcome and Introduction
• Get a Handle on Denials in the Post-
ICD-10 World
• Kareo’s Role
• Answer Questions

@GoKareo 33
Speaker
Betsy Nicoletti, MS, CPC
 Speaker, writer, and consultant in coding
education, billing, and accounts receivable
 Author of The Field Guide to Physician
Coding
 Founder of Codapedia.com
 Developer of The Accurate Coding System
 MS in organization and management
 20 years experience in medical coding
 Member of MGMA & the National
Speakers Association

Kareo Confidential 44
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Agenda
5
Agenda
5
ICD-10 World
• Kareo’s Role

@GoKareo 66
Our Agenda
• Hoping for the best, preparing for the worst—watching
for and managing denials
• Sending out accurate claims, protecting our revenue
stream
©2015 Betsy Nicoletti

@GoKareo 77
Announcement on an Amtrak Train
“Important change
coming October 1st!”

@GoKareo 88
Probably not Approving Vacations for October
• Claims submitted for DOS
9/30/15 will use ICD-9
• Claims submitted for DOS
10/1/15 and later will use
ICD-10
• Cannot submit ICD-9 and
ICD-10 on the same claim

An ounce of prevention…
Is worth a pound of cure

@GoKareo 1010
Do You Have a Denial Management Program?
• The payer’s reimbursement rules are not changing
• The basics of diagnosis coding aren’t changing
• Do you track denials by reason code now?
• Do you give feedback to front desk staff, coders, billers
and clinicians now?
• Do you have a baseline of current denials?

@GoKareo 1111
CMS Announcement and Caveats
https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-
Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/AMA-CMS-
press-release-letterhead-07-05-15.pdf
“Family” of code—clarified to
category
Must still meet NCD/LCD
requirements
Valid code Pay attention to non E/M
services

@GoKareo 1212
CMS Caveat
• Only for fee-for-service Medicare, not Medicare
Advantage, Medicaid, or commercial payers
• Valid, within the family
• One year grace period for unspecified codes
• Payer policies and reimbursement policies haven’t
changed

@GoKareo 1313
Clearinghouse Reports
• Claims rejected by clearinghouse
• Claims rejected by the payer
• Review promptly
• Do you have access to a report of denials by diagnosis
code now? Or procedure code?

@GoKareo 1414
Rule Out other Causes
• Many reasons for claim denials, pre or post
adjudication
• Wrong payer
• Eligibility/coverage
• Keying errors
• Place of service
• Provider enrollment
• Place of service

@GoKareo 1515
Reason Codes Related to Diagnosis
• Not all denials will be related to ICD-10
• Look at CARC (claims adjustment reason codes)
• And, RARC (remittance advice remark codes)
• Available at: http://www.wpc-edi.com/reference/
• MedLearn Matters Article:
https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/mm6229.pdf

@GoKareo 1616
Essentials In Denial Management
• Business as Usual
• Fix and resubmit and then…
Off with her head

@GoKareo 1717
Why was the claim
denied?
System improvements
Categorizing reasons
for denials into broad
categories
Fix, resubmit, repeat…
Data into useful
information
Education
Process improvement

@GoKareo 1818
Reason Codes after 10/1/15
• Sort denials by payer—do you
have one or two payers who are
not ICD-10 ready? Don’t wait till
Halloween to find out
• Highlight diagnosis related denials

Medical necessity is like beauty…
Often in the eye of the beholder

@GoKareo 2020
Medical Necessity: one MAC
• CO-50, CO-57, CO-151, N-115 - Medical Necessity: An
ICD-9 code(s) was submitted that is not covered under
a LCD/NCD.
• Check the LCD or NCD prior to service to determine
eligibility of services for patient. If the service being
performed is not covered under the LCD guidelines, we
encourage you to provide your patients with an ABN
prior to performing these tests.

@GoKareo 2121
MAC—Specific Procedure
• Denial Reason, Reason/Remark Code(s)
CO-50, CO-57, CO-151, N-115 - Medical Necessity: An
ICD-9 code(s) was submitted that is not covered under
a LCD/NCD CPT codes: 93307, 93320, 93325
• Resolution/Resources
Refer to the 'Transthoracic Echocardiography' Local
Coverage Determination (If the service being
performed is not covered under the LCD guidelines,
we encourage you to provide your patients with an
Advance Beneficiary Notice (ABN) prior to performing
these tests)

@GoKareo 2222
Worker’s Comp
Not required to transition to ICD-10, because not a HIPAA covered entity
http://www.wedi.org/knowledge-center/resource-view/resources/2014/02/27/workers-compensation-icd-10

@GoKareo 2323
Line item and claim level denials—non-ICD-10
Bundling Demographics
Modifiers Pre-authorization

@GoKareo 2424
Some Codes Have Laterality In ICD-10

@GoKareo 2525
Bilateral Diagnosis Codes
• Frequent in eye, ear, MS, vascular, and injury.
• For some, right, left, bilateral, unspecified; for some,
right, left, unspecified.
• Your CPT code will still require modifier 50 for
bilateral, or RT/LT even if diagnosis code states right,
left, or bilateral.

@GoKareo 2626
ICD-10 Diagnosis Denials
• Is the code a valid code? Could be: 3-7 characters
• Does the code require a 7th character and it was
omitted?
• Is the service covered under a Medicare NCD/LCD or a
payer policy?

@GoKareo 2727
An Incorrect 7th Character May Cause Denials
• Used with injury and external cause codes, 7th
character must always occupy the seventh character
position in a code.
• Choices for 7th character for some injuries:
• A: Initial encounter (think, active)
• D: Subsequent encounter (think, healing,
routine follow up)
• S: Sequela

@GoKareo 2828
Aftercare Codes May Cause Denials
Key change in ICD-10
• Aftercare codes are used for aftercare of a surgical or
medical procedure
• The aftercare of trauma and injuries are coded with
the injury code with a different 7th character extender

@GoKareo 2929
External Cause Codes
• Greatly expanded
• Equivalent of E codes
• Watch for denials or claim slow downs
• Optional—payer driven

@GoKareo 3030
Sequencing and Linking
• Like in ICD-9, many sequencing instructions in ICD-10
• For physician practices rare denials based on
sequencing
• Linking is critical

@GoKareo 3131
What Is Linking?
• When submitting a claim for more than one CPT code,
there are times when there is a different diagnosis for
each procedure
• Link the correct CPT and diagnosis codes
• Office visit for hypertension
• Lesion destruction for a lesion

@GoKareo 3232
Coverage Determinations
• For diagnostic tests, coverage manual list CPT code
and covered diagnosis codes
• Many other procedures (preventive services, medical
tests, foot care, hyperbaric oxygen therapy, bariatric
surgery—have Medicare local or national coverage
policies
• Private payers and Medicare Advantage: their own
policies

@GoKareo 3333
Unspecified, Unspecified
• Only fee-for-service Medicare has announced
payment for unspecified codes
• Try not to use any code with the word “unspecified”
twice
• S93.409A Sprain of unspecified ligament of unspecified
ankle, initial encounter
• Avoid codes at the end of the category: M1A.9 Chronic
gout, unspecified or H10.9 Unspecified conjunctivitis

@GoKareo 3434
Service Line Problems
• Watch, run reports by:
• Diagnosis injury codes S00-T88
• Diagnosis OB codes O00—O9A
• CPT codes for diagnostic tests (70000 and 80000)
• Medicine codes for tests (pulmonary, cardiac, HEENT)

@GoKareo 3535
Software
• If you weren’t able to test in September, you’re testing
now in October
• Does your software allow you to use invalid codes?

@GoKareo 3636
• Denial percentage by payer, line item, claim, type of
service
• Frequency of claims rejected or suspended by
clearinghouse, and reason
• Volume and dollar value of denials by reason

@GoKareo 3737
Are You Relying on Mapping?
Look at the results!
• Unspecified because
the ICD-9 code was
unspecified
• Or, ICD-9 code was as
specific as possible but
there are more options
in ICD-10

@GoKareo 3838
Our Response
• Coding denials routed to coders
• All diagnosis related denials reviewed with manager
and physician leader
• No batching for later
• Establish time thresholds for review/resubmission

@GoKareo 3939
Increase Specificity of Coding
• Review problems in problem
list
• Check all mapped codes
• Run a frequency report,
identify unspecified codes
• Educate, educate, educate

@GoKareo 4040
In ICD-9
• Look at your current ICD-9 diagnosis related denials
• Find and review NCDs, LCDs and private payer policies
for services with denials

@GoKareo 4141
Review
Two pairs of eyes on all
clearinghouse reports,
diagnosis related denials
and denial reports by
payer and percentage

@GoKareo
Agenda
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Agenda
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Agenda
48
Agenda
48
ICD-10 World
• Kareo’s Role

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Getting a Handle on Denials in the Post-ICD-10 World

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