by Sarah Hanna
November 18, 2015

After months of preparation, ICD-10 descended upon us October 1.

The deadline approached with much dread throughout the health care continuum. The worries and the stress of the unknown have been driving the industry mad. Now that we are in full swing with ICD-10, it is important to track and trend information regarding the effects of ICD-10 on your operations.

There are four areas that need to be reviewed to monitor the effects of ICD-10:

  1. Holding revenue
  2. Electronic claim front-end rejections
  3. Claim adjudication delays
  4. Denials

Holding Revenue

As intake receives referrals and billing reviews claims prior to submission, claims will be placed on hold waiting for the ICD-10 code if the ICD-9 code is the only diagnosis code present. The key is to have a process in place for following up on those claims on hold. Monitoring any spikes in your holding revenue regarding ICD-10 is one of the keys to maintaining cash flow. You need to have a specific hold reason so that everyone who is involved identifies those claims in a uniform manner. This is critical for reporting.

If your holding revenue increases and the cause is claims waiting for the appropriate code, ask your team the following:

  • Has the correct information been received and the claim never been released from hold?
  • What is the process for following up on gaining the code?
  • Has the process been followed? If not, why?
  • How can the process be improved?
  • What challenges is your team encountering when gaining the new code?
  • Are there specific referral sources that are holding the most dollars by lack \uc0\u8232 of response?
  • To reduce the backlog of claims on hold, will additional team resources need to be involved and how will those people be best utilized?

Once you have found the answers, make a plan to move forward and continue to monitor for a decrease in those holds.

Electronic Claim Rejections

Claims can be rejected on the front end (before the payer sees and accepts them) for errors due to ICD-10. Some rejections will cause the entire batch of claims to reject and others will cause only an individual claim to reject. There are standard Common Electronic Data Interchange (CEDI) rejection codes that billers can look for and should be aware of. On September 4, CEDI provided a listing of front-end edits that could be returned on various reports, which are then translated by your software or clearinghouse.

The 999 report is the first report that providers get back that tells you if the whole batch was accepted or rejected. For example, the diagnosis code qualifier must be present for each diagnosis code, and a second diagnosis code cannot be reported unless a primary diagnosis is reported.

Once the file batch is accepted, CEDI can then choose to reject certain claims. The ICD-10 specific rejections are listed below:

  • Primary Diagnosis Code—The primary ICD-10 code is not a valid ICD-10 code or is not valid for the date of service.
  • Diagnosis Code—The secondary ICD-10 code is not a valid ICD-10 code or is not valid for the date of service.
  • Invalid Character—The ICD-10 diagnosis code must not contain a decimal.
  • E-Code—ICD-10 codes that begin with letters V, W, X or Y are not allowed.
  • Diagnosis Codes—Cannot have both ICD-9 and ICD-10 codes on the same claim.

Additionally, pay attention to claims that require a date span. These will show up on your rejection reports. For Medicare, DME claim edits will only look at the first date in a date range—for example a claim with range from September 5, 2015, to October 4, 2015, would use ICD-9, even though the claim overlaps the ICD-10 launch. A claim with a range from October 2, 2015, to November 1, 2015, would use ICD-10, because the claim was initiated after the arrival of ICD-10.

However, be aware that some commercial payers may not follow the same date span philosophy as Medicare. Find out what your payers are expecting and educate your team to meet those expectations.

Start trending the current number of rejections. Look for spikes and designated reasons for the rejection. Ensure that your biller is working her rejections within 24 hours of the receipt of those rejections. Accounts receivable (AR) can increase due to lack of attention to those rejections. Don't wait until this has become an issue and found while working the AR. Collectors can find this to be an issue when following up on claims and there is "no claim on file" or "no record of claim."

Billers should be able to tell management the number of rejections per submission that are attributed to the diagnosis code. If the number has increased, then measures need to be taken to investigate why they are occurring and what the team is missing in their claim review prior to submission.

Claim Adjudication Delays

Know the average turnaround time for your top payers and track their behaviors. Most providers know when their major payers process their checks and when those will be deposited into their accounts. If the turnaround time increases, contact your provider representatives for inside information and assistance in the case of prolonged delays. Remember this is not just a Medicare change; it is all of your payers with the exception of worker's compensation and auto claims.

Claim Denials

If you are not already doing so, start trending your denials. Look for increases in denials, especially those designated with the American National Standards Institute (ANSI) denial reason code 16 partnered with an ANSI remark code of M76—which means "missing/incomplete/invalid diagnosis or condition."

Approach the denials in the same manner in which you would the rejections. It is vital to trend your data and assess the spikes so that you are acting quickly. Waiting until you see your AR increase in the more than 120-day bucket will cause more issues than proactively reviewing the processes and numbers that affect the AR in the less than 90-day bucket.

Being informed by monitoring your data will assist when navigating the stormy seas of our industry. One thing that can be said about our little slice of the health care pie is that you will never be bored—there is always something to raise your blood pressure.