Provider Risk in ICD-10

Mario Fucinari DC, CCSP, MCS-P

On July 7, 2015, the acting administrator for the Centers for Medicare and Medicaid Services (CMS), Andrew M. Slavitt, sent out a notice to all providers that CMS would be lenient in processing of the claim forms as long as provider’s codes are in the correct family of codes. On its face, this may seem as if CMS has become more lenient in their policies. Is this the case or is CMS sending out a warning of an impending increase in audits?

As of October 1, 2015, the ICD-10 coding system will go into effect. The long awaited coding system will increase the amount of available diagnosis codes from 17,000 to nearly 70,000 choices. The World Health Organization (WHO) is responsible for the changes in the system, while CMS is responsible for implementing the system in the United States. The marked increase in the amount of codes available is because of the increased specificity of the codes.

The coding system acts as a source of collecting global data throughout the world. Only in the United States are the codes used for reimbursement. The rules for implementation modified by CMS are known as the clinical modifications. After establishing the clinical modifications, each carrier will further clarify their policies on how they want to use and process the codes. As if the utilization of the 70,000 code set was not daunting enough, we must also navigate through the carriers’ policies for the ICD-10 reporting. The common theme among all carriers is that the documentation must support the diagnosis code utilized.

In their July notice, CMS stressed in bold font that their “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review, based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/practitioner used a code from the right family.”

An ICD-10 code is made up of subparts of the code that yield information. The first part is known as the “family”. The other portions tell of the etiology, the side, and the stage of care the patient is experiencing. In our example, “S13” represents a sprain injury to the ligaments of the neck region. This is in comparison to “S16”, which is an injury of the muscle, fascia and tendon at the neck level. While one is a strain (S16) and the other is a sprain (S13), they are both a covered service in the chiropractic scope of practice.

S13 is the family in S13.4xxA

If we couple the statements that the documentation must support the code and that the codes will be accepted as long as they are in the same family, it begs one to ask – How will they know? Carriers have always done spot checks and audits as a way to ensure that the care you provide is medically necessary. I do not foresee a change in that policy. Data mining and profiling your claims makes this process even easier for carriers to choose the provider to audit.

We have long known that all insurance carriers profile providers. To skirt around the system, some providers have become “cash only” offices. In my opinion, a cash only office is non-existent, since you must file a claim for active care in a Medicare case. Even in the non-Medicare patient, the patient will file a claim with their insurance company. This indirectly profiles the physician and their office. The only answer is to make sure your examination and your documentation is specific so as to best explain your choice of the diagnosis code you used. In diagnosis, you must always diagnose what you know. ICD-10 is a different language. All providers should be compelled to learn the new language thoroughly.

As always, your documentation is your lifeline to safety. Risk management, reimbursement and audits always depend on the safety net provided by documentation. In the coming months, be aware of the clarifications in the usage of ICD-10 codes. Since others are watching you, you have to be wary of the picture you are painting.

Dr. Fucinari is a frequent national speaker on compliance, Medicare and ICD-10 coding. For an updated schedule of classes and locations, go to www.AskMario.com. Dr. Fucinari is the author of several books, including, ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office, available at www.Askmario.com. Dr. Mario Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. For further information on chart audits, compliance audits, manuals or consulting, please contact Dr. Fucinari at Doc@Askmario.com.