ICD-10 progress report
How have practices and payers handled the transition, and what have we learned?
By Jeff Grant
We’re two months into the ICD-10 transition, and the insurance-claim adjudication systems haven’t come crashing down — yet. In fact, the changeover has surpassed even my largely positive expectations. Claims are going out, being processed, and, for the most part, are being paid.
It appears that payers updated their systems to process ICD-10 codes and accurately adjudicate claims with ICD-10 codes (again, for the most part). Further, based on CMS’ release of claims data for the period Oct. 1-27, 2015, rejections rates for the period after the ICD-10 implementation equaled or were less than the historical baseline (see sidebar, page 44). This evidence shows the success of the ICD-10 implementation thus far.
For practices with problems beyond payer-related, the blame falls squarely on the shoulders of practice leaders who failed to prepare.
The following list explains the most immediate and significant things we have learned so far about ICD-10 coding, surprises we’ve seen along the way and previously forgotten items your revenue cycle management team should enforce.
Unspecific diagnosis (Dx) codes
A month or so before the Oct. 1 implementation date, CMS issued guidance allowing you to send unspecified ICD-10 codes. This flexibility covers only one year, though (through service on and prior to Sept. 30, 2016). I suggest you do not get in the habit of using unspecified codes. Rather, focus on coding as accurately and completely as possible so you do not form habits you will only need to change a year from now (use this link for CMS’ guidance: www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf).
Condition codes with injury/trauma dx codes
Contrary to many people’s belief and the coding scenarios I’ve seen on many of the ophthalmology-related email groups, you don’t need to include condition codes with injury/trauma codes (use the following link for CMS’ guidance (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1518.pdf).
Billing bilateral surgeries
In ICD-9, you used one code for both eyes. It’s become a bit more complicated with ICD-10, especially with cataract surgery because you usually bill for two surgeries as well as two IOLMasters or A-scans.
Here’s a guide for billing bilateral cataract surgeries (Ann Rose’s input on this topic in the early days of the ICD-10 transition was very valuable):
• Initial exam that determines the need for surgery. Bill the bilateral ICD-10 code (H25.13 for example).
• IOLMaster/A-scan/Cataract signs and symptoms (sx) for the first eye. Bill the ICD-10 code for the eye on which the services were performed (H25.1_).
• IOLMaster/A-scan/Cataract sx for the second eye. Bill the ICD-10 code for the eye on which the services were performed (H25.1_).
Routine dx codes
In ICD-9, many practices used V72.0 to bill medical payers for exams provided to patients with routine vision coverage. ICD-10 uses two “routine exam” dx codes instead of one:
• Z01.00 (without abnormal findings)
• Z01.01 (with abnormal findings)
If you use Z01.01, ICD-10 requires you to “use additional code to identify abnormal findings.”
Mistakes in LCDs
HCMA (my billing company) and others quickly discovered that many of the updated LCDs (those that went into effect on Oct. 1 and include ICD-10 codes instead of ICD-9 codes) were missing dx codes that should be payable (ICD-10 equivalents to the previously listed ICD-9 codes). Thankfully, most Medicare Administrative Contractors (MACs) acted very quickly to get these issues corrected. Here are some examples:
• CGS Administrators denied charges for IOLMaster (92136) when billed with ICD-10 codes H25.11, H25.12 and H25.13 (equivalent to 366.16). We emailed CGS on Oct. 16 and received this response on Oct. 21:
“The Part B Medical Review Department has reviewed Local Coverage Determination (LCD) L34181, Ophthalmic Biometry for Intraocular Lens, and is currently making the necessary update to add additional diagnosis codes, including code H25.12. Please allow seven (7) business days for both the LCD and our system to reflect this correction. Claims previously denied in error, may be adjusted shortly.”
• WPS Health Solutions and Humana Medicare Advantage deny age-related codes (H25.11 through H25.13). We’ve seen this with cataract surgeries and IOLMaster.
• WPS Health Solutions missing some bilateral ICD-10 codes (LT eye code and RT eye code are listed as covered, but not the bilateral code).
• Novitas had an issue in which it denied ophthalmic diagnostic imaging when billed with “diabetic retinopathy w/ macular edema diagnosis” codes. This has been corrected.
• First Coast had an issue in which visual fields were denied when billed with glaucoma suspect dx. This has been corrected.
If you have an issue, contact your MAC. Some of them created a process to act quickly on reports of LCD/payment errors. Be sure to have clear evidence, such as reference to previous LCD containing ICD-9 lists and LCDs from other MACs with correct ICD-10 lists. If you can’t get resolution from your MAC or if it won’t take your concerns seriously, contact CMS’ ICD-10 ombudsman (ICD-10_Ombudsman@cms.hhs.gov).
|Metrics||October 1-27, 2015||Historical baseline*|
|Total claims submitted||4.6 million per day||4.6 million per day|
|Total claims rejected due to incomplete or invalid information||2.0% of total claims submitted||2.0% of total claims submitted|
|Total claims rejected due to invalid ICD-10 codes||0.09% of total claims submitted||0.17% of total claims submitted|
|Total claims rejected due to invalid ICD-9 codes||0.11% of total claims submitted||0.17% of total claims submitted|
|Total claims denied||10.1% of total claims processed||10% of total claims processed|
Metrics for total ICD-9 and ICD-10 claims rejections were estimated based on end-to-end testing conducted in 2015 since CMS has not historically collected this data. Other metrics are based on historical claims submissions.
Even though visits during the postoperative (PO) period are not payable and do not need to be billed, some practices want to code these encounters correctly (and a few bill them to insurance). For exams during the 90-day postoperative period, you can code Z98.4-, cataract extraction status, plus Z96.1 to identify the presence of an IOL. For routine care after the PO period, use Z96.1 only.
Refractive dx codes to Medicare
Several MACs denied encounters billed with refractive dx codes even when there are payable medical dx codes on the claims and when the medical codes are linked to the service. It’s probably best not to include refractive dx codes on your Medicare claims.
Workers’ Compensation payers and ICD-10
Workers’ Compensation (WC) payers aren’t required to adopt ICD-10, but many states have chosen to require WC payers in their state to use ICD-10. For a list that details WC ICD-10 readiness in each state, visit www.wedi.org/docs/resources/wedi-icd-10-state-workers-compensation-readiness-list.pdf.
So far, most people’s worst fears about the ICD-10 implementation haven’t come true. But, we’re sure to discover more nuances of proper ICD-10 coding for ophthalmic services, and because some payers (especially secondary and tertiary payers) haven’t had time for claims to go through their system yet. OM
About the Author
Jeff Grant is founder of HCMA, Inc., which specializes in revenue cycle management services, as well as management & operations consulting for ophthalmology practices. E-mail him at firstname.lastname@example.org.