Brad Hart, MBA, MS, CMPE, CPC, CPMA, COBGC, and the Association for Maternal Fetal Medicine Management
Mr Hart is President of Reproductive Medicine Administrative Consulting in West Orange, New Jersey, and a faculty member for the American Congress of Obstetricians and Gynecologists (ACOG) Coding Workshops and Webcasts. His website is www.obgyncoding.com and he can be reached at firstname.lastname@example.org.
Important dates in the history of medical billing and coding:
• January 1, 1966-The publication of the first edition of Current Procedural Terminology (CPT).
• October 1, 1979-The effective date for the mandatory usage of the International Classification of Disease, Clinical Modification 9th edition (ICD-9-CM) as the designated code set for reporting diagnoses to the Medicare and Medicaid programs.
• January 1, 1992-The effective date for the usage of Evaluation and Management (E/M) codes in the CPT book, as well as the implementation of the Resource Based Relative Value Scale (RBRVS) as the framework for Medicare physician reimbursement.
But none of these dates is as significant as October 1, 2015-the effective date for implementation of ICD-10-CM. It is the most significant because, unlike the other dates, this change affects every claim for every provider in every specialty in every healthcare setting in the United States. In addition, the complexity of the healthcare reimbursement process has increased exponentially in the past few years. This transition literally changes half of the language with which we communicate with third-party payers, in the context of that more complex environment.
The date is unusual in that it has passed, but we are only now beginning to fully understand the ramifications of the new code set. What is this brave new world of ICD-10-CM going to look like? What do we need to be doing about it now?
Fortunately, obstetricians and gynecologists have a less complex ICD-10-CM transition than physicians in other specialties. Gynecologists must now more frequently distinguish between acute and chronic and primary and secondary conditions, report laterality in some very limited circumstances, and provide more details with regard to certain disease processes. Specifically, their documentation must be more detailed in these areas to facilitate correct code selection (see sidebar).
For obstetricians, the documentation needs for ICD-10-CM have not changed significantly, relative to ICD-9-CM. The information needed for ICD-10-CM most likely already exists in the medical record. However, the degree and specificity of information that must be reported to payers has changed substantially. Accumulating this more detailed information for billing purposes and accurately reporting it to payers is going to be the most significant challenge.
The first part of the challenge is internal: Are the appropriate codes being selected and reported accurately and efficiently? The second challenge is external: How are the payers going to respond to the claim submissions and how effective are they going to be in doing their job of processing claims properly?
Compared to providers, payers have had a more intense job in preparing for ICD-10-CM. They will be actively processing both ICD-9-CM and ICD-10-CM claims for quite some time to come as providers run out their outstanding claims from prior to October 1, 2015. Therefore, they need to have systems in place to facilitate dual diagnosis systems. More significantly, every one of their payment policies, which had been driven by ICD-9-CM codes, had to be transformed to accommodate ICD-10-CM. In addition, they had to train their employees in ICD-10-CM codes, just like providers did.
Were payers ready? Based on their vociferous objections to the unexpected delay in 2014, it seemed that they thought that they were fully prepared to proceed at that time. However, the final answer to that question is: yes and no. Some have done an excellent job; some, not so much. In fact, as of October 1, the Medicaid programs for 4 states (California, Louisiana, Maryland, and Montana) were not prepared to process claims submitted with ICD-10-CM codes. (They will be taking these claims and cross-walking them back to ICD-9-CM for payment.) What is clear is that none of the payers did a perfect job of translating codes from ICD-9-CM to ICD-10-CM, which may adversely affect claim payments, and their employees are not experts in ICD-10-CM. Then again, at this stage, there are not many individuals who would fall into that category.
As a result, ob/gyn practices need to be ready to move forward in the current environment, which will require some adaptation and flexibility. Before that adaptability and flexibility can occur, practices must develop a full understanding of the environment and recognize their needs-preferably sooner, rather than later.
Training. It is a common misconception to think, “Training for ICD-10-CM is over! Let’s get on with business!” The most effective training is yet to come. Before October 1, many would ask the question, “How are the payers going to respond to _____________?” The honest answer was, “We don’t know.” At that point, no one had submitted a live claim to a third-party payer in the United States, therefore, all the training centered around the principles of ICD-10-CM and not on the practical matter of turning that coding into revenue.
The fact that no one had submitted a live claim contributed to a related problem. They didn’t know what they didn’t know. If the payer is an entity subject to the Health Insurance Portability and Accountability Act (HIPAA), it must accept ICD-10-CM codes. However, there is nothing in HIPAA that mandates that the payer interpret the codes according to ICD-10-CM principles or that it must pay claims when a particular diagnosis is used. Payers have the prerogative of determining their payment policies and defining what diagnosis codes can or should be used in a given circumstance. Unfortunately, unless one finds the time to read the entirety of the payers’ coverage policies (if they are available online), some of the major problems will not be identified until post-10/1 Explanations of Benefits (EOBs) are received.
As mentioned earlier, virtually no one is an expert in ICD-10-CM yet, and so, training must continue aggressively. This training should be better and more targeted because there will now be an understanding of how payers are handling claims in the real world.
Communication. There are 2 extremes in communication that happen in the business world, particularly in the context of the healthcare business world. They are:
We operate in “silos.” Management consultant Phil Ensor first coined this term in 1988 to describe a situation in which one person in an organization has an important piece of information, but is not aware of the need or lacks a proper system to facilitate communication of that information. As a result, an individual or small group of people know key facts, but the remainder of the organization continues on unaware of this information, which is easily available. Due to the lack of communication and the channels to facilitate it, reimbursement may be delayed because information is not being effectively shared internally.
The other extreme occurs when one piece of information is improperly extrapolated beyond its level of importance. Too frequently when working with clients, I am told, “________ is not covered when we use that code.” When I ask the source of that information, there often is no identifiable source. Too often, a single payer responded to a particular claim in a certain manner. That payment (or denial) is reported far and wide within the organization and it becomes an urban legend, applicable to all payers in all circumstances. Again, unnecessary delays in reimbursement occur because we are applying policies that do not exist to payers that never had that policy in the first place.
Appropriate communication solves both parts of this problem. Important information needs to be shared far and wide across an organization. Practices need to eliminate the inefficiency of repeatedly making the same error when the key to proactive avoidance of the error resided “in house.” In contrast, groups should ensure clarity in homegrown communication. Avoid the universal application of information to every payer in every circumstance, unless it is actually a fact. Ensure that your staff asks clarifying questions such as, “Who was the payer?” “What was the circumstance?” “What was the source of this information?” The value of communication is fully realized only when the information being communicated is completely accurate.
Measurement. You can evaluate only what you can measure. This is going to be the key element in the early identification of ICD-10-CM implementation problems. To guarantee success, you must be able to quickly and accurately answer the following questions:
1. On September 1, 2015, what was the average length of time from the date of service until the date of charge posting? Then, on November 1, 2015, what was the average length of time from the date of service until the date of charge posting? Is it longer, shorter, or the same? If it is significantly longer, it may indicate that your staff is being challenged by the transition.
2. What were your charges for the month of September 2015? What were your charges for the month of October 2015? What were your charges for the month of October 2014? After you have considered any factors that may influence the charges (eg, the addition or departure of providers, the addition or loss of an insurance contract, etc.), what is the variance, if any? If the circumstance-adjusted comparison (especially in the year vs year analysis) reveals a substantial variance, the question, “Why?” must be immediately answered. This could indicate a problem either with charge submission by providers or with data entry by billing/coding staff.
3. What were your payments during the time periods described in question 2? If circumstance-adjusted payments are down significantly, there may be several different factors at play:
· Charges aren’t being entered/submitted in a timely fashion.
· Payers are slowing down their claims processing.
· Payers are responding to your claims-they are just denying them.
4. What are your days in accounts receivable (A/R)? Is it a substantial change from the pre-implementation period? An increase in days in A/R is not unexpected in this environment. However, this must be watched carefully to ensure that it does not balloon to unacceptable levels, from which it becomes difficult to recover. As in the case of a payment analysis, an increase in A/R days may indicate an issue with payer response to claims, the practice’s response to claim denials, or both.
5. What was your pre-ICD-10-CM claim denial rate? What is your post-ICD-10-CM claim denial rate? No practice has a 0% denial rate, usually because claims are denied for reasons beyond the control of the practice (eg, the patient changed insurers and didn’t inform the practice) and the fact that human beings are part of the process, making 100% perfection a laudable but unachievable goal. However, if there is a dramatic increase in the denial rate, some questions must be answered:
Are claim denials the result of:
· Errors in coding on the part of the practice?
· Errors in processing on the part of the payer?
· Problems with electronic transmission to the payer via the clearinghouse?
Whatever the answer(s), finding a timely resolution is essential to the financial health of the practice.
Strategize. Being able to answer all of the measurement questions mentioned above will accomplish nothing without a plan to respond and adjust to the issues. Ideally, this would have taken place prior to ICD-10-CM implementation, but it is not too late to develop a plan now. A one-size-fits-all strategy does not exist because varying practice characteristics will lead to different problems in different organizational cultures and environments. However, the consistent elements to consider are:
Staffing. Are current staffing levels sufficient to handle the transition? If not, how will your team address the problem? Authorizing overtime? Hiring temporary staff? Outsourcing data entry? All these methods are appropriate options, but each has its risks, benefits, and consequences. The correct solution in one environment may be the wrong one in another.
Also, who will take on the essential but tedious task of carefully reviewing EOBs from payers to ensure that denial reasons are clearly understood and make certain avoidable denial reasons do not occur repeatedly in the future?
Education/Communication. In some settings, especially in larger practices, formal education sessions may be appropriate. In other settings, a more informal approach may be the most appropriate alternative. Regardless of the modality, effective communication among providers, billers/coders, and managers is the key to success in this transitional period.
Response to payers. Some are going to have the unhappy experience of dealing with a payer who appears to have been unprepared for the transition. It is not going to be helpful to complain to each other about the payer. Some payers have established ICD-10 hotlines or ombudsmen. Take advantage of pre-existing contacts with a particular payer. If that does not work, ask for assistance from your State Insurance Commissioner-especially if payers are denying claims inappropriately or are violating timely filing rules in your state. Other organizations, such as the American Congress of Obstetricians and Gynecologists (ACOG), have third-party payer complaint forms to help navigate problems. They may offer another means to help.
In some regards, ob/gyns have it easier with the ICD-10-CM transition than do providers in other specialties. However, the unique nature of the global billing process for obstetrics is going to produce a set of circumstances that providers in other specialties won’t experience. What should we do when reporting services for an obstetric patient whose billing must be split or unbundled? (See the case study for an example.) In addition, we must be certain that we are accurately reporting the appropriate stage of pregnancy (eg, trimester) and number of weeks’ gestation for each encounter. Are we accurately capturing all of the appropriate diagnoses at the time of delivery to fully report the patient’s condition and complications?
We have been using ICD-10-CM for a few weeks now. It remains to be seen how many years it will be part of our professional lives. History would suggest that it will be with us for quite some time to come. The sooner we can become comfortable with it, incorporate it into our work flows, and take advantage of the features it has to offer, the sooner we can fully experience its benefits and also experience stable cash flows into our practices.
A case study in ICD-10 challenges for ob/gyns
Susan presents for her initial OB visit at 8 weeks, 2 days’ gestation on September 28, 2015. It is her first pregnancy. She also is seen at scheduled visits at 12 weeks (October 27), 16 weeks (November 23), and 20 weeks (December 22). At that visit, she tells the doctor that she and her husband are relocating to another city and she would like her records transferred to an obstetrician in that city.
Q. How should the physician bill for these services?
A. 59425 (4-6 antepartum visits) with a date of service of 9/28/15, using an ICD-9-CM code (V22.0)
B. 59425 with a date of service of 12/22/15, using an ICD-10-CM code (Z34.02 or Z34.00)
C. Separate E/M services for each encounter with appropriate ICD-9-CM and ICD-10-CM codes (9/28-V22.0; 10/12-Z34.01; 11/23-Z34.02; 12/22-Z34.02)
D. Some other option
A. It depends on what the payer wants. Each option could conceivably be used and not be incorrect. Communication with the payer is absolutely essential in cases like this to obtain the appropriate reimbursement.
Coding changes relevant to ob/gyns
Charles J Lockwood, MD, MHCM
There are twice as many obstetrical codes in ICD-10-CM (2,155) as in ICD-9 (1,104).1 These new codes add specificity to the characterization of obstetrical conditions. As noted, the ICD-10-CM obstetric codes are listed in Chapter 15. These codes have sequencing priority over those from other chapters and start with the letter “O,” not the number zero.
Unlike the ICD-9 codes, ICD-10-CM obstetrical codes are not divided by antepartum, delivery and postpartum status. Most new codes indicate the trimester of pregnancy in their final character.2 An additional code from category Z3A should be used to define specific weeks of gestation (eg, Z3A.42 would indicate 42 weeks’ gestation). The Z codes connote reasons for encounters in the ICD-10 system.
There are now more codes to describe the nature of medical complications in pregnancy. For example, when diabetes complicates pregnancy, it can be further classified as pre-existing (type 1 or 2) and by the trimester in which the encounter occurred (eg, O24.011 defines “Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester”). Alternatively, gestational diabetes can be described along with its treatment (O24.011 defines “Gestational diabetes mellitus in pregnancy, diet controlled”).
Conversely, routine office visits during uncomplicated pregnancies require a code from category Z34 (“Encounter for supervision of normal pregnancy”) as the first-listed diagnosis, but no codes from Chapter 15.3 When a patient has had a full-term uncomplicated delivery of a healthy singleton fetus following an uncomplicated pregnancy and postpartum course, code O80 is used and no others from chapter 15. This code should be accompanied by Z37.0 (Single live birth) as the only outcome-of-delivery code.
The ICD-10-CM codes for elective abortion are contained in Chapter 21 (Factors Influencing Health Status and Contact with Health Services). As noted, Chapter 14 (N00-N99) itemizes diseases of the genitourinary system, which include diagnoses related to the female reproductive and urinary tracts.
As noted above, in ICD-10-PCS, obstetrical procedure codes are designated by the number 1 in the first character of the code, as opposed to medical and surgical procedures, which are designated by the number 0 (zero). For obstetrical procedures, the second character is 0 (zero), connoting pregnancy, and procedures are further characterized by the remaining 5 digits. Conversely, gynecological surgery is listed under the medical and surgical first character 0 (zero), and then by second character U indicating the female reproductive body system (ie, 0U) and further defined by the other 5 digits (note that while U is not used in ICD-10-CM codes, it is used for PCS codes).
1. Carmichael A. Exploring ICD-10-CM’s Chapter 15: pregnancy, childbirth & the puerperium. http://www.icd10monitor.com/index.php?option=com_content&id=415:explorin.... Accessed August 20, 2013.
2. AAPC. Ob/gyn quick reference for ICD-10-CM. http://cloud.aapc.com/documents/OB-GYN-Quick-Reference_ICD-10-CM.pdf. Accessed August 20, 2013.
3. ICD-10 coding fact sheet: obstetrics and gynecology. http://www.gkcmma.com/sites/www.gkcmma.com/files/resources/ICD-10_OBGYN_.... Accessed August 20, 2013.