Industry Insights

An ICD-10 Game Plan:  Essential for Senior Living Providers to Prevent Payment Delays

September 2015
Author:  Suzy Harvey

Suzy Harvey

Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

All providers have been warned by the Centers for Medicare & Medicaid Services (CMS) that ICD-10 is coming, but with multiple delays the past two years, many senior living providers are unprepared for this transition. All entities covered under the Health Insurance Portability and Accountability Act (HIPAA) will be required to use ICD-10 code sets beginning October 1, 2015. This change may be especially difficult for senior living providers, which—unlike other provider types—typically do not employ certified coders, leaving coding up to medical records or nursing departments that often have no formal coding training. When billing for October service dates, claims without accurate ICD-10 coding will not process, bringing payments to a screeching halt. 

The ICD-10 implementation date varies based on the type of claim, but for skilled nursing facilities (SNF), the following cutoffs apply:

  • Part A SNF claims containing a discharge and/or through date on or after October 1, 2015, must contain ICD-10 codes on the claim.
  • Part B SNF claims for both inpatient and outpatient services will require any claims with a “from” date of October 1, 2015, or later to contain ICD-10 codes on the claim.

Providers are not allowed to dual code claims for services prior to October 1, 2015. Claims prior to October 1, 2015, should contain ICD-9 format, and claims on or after October 1, 2015, should use ICD-10 format. Claims not containing accurate or complete ICD-10 codes will not process and will be returned to the provider in the Medicare direct data entry claims processing system. State Medicaid programs and insurance companies should follow the same guidelines for accepting ICD-10 format; however, providers should check with individual payors for their specific requirements.

Game Plan

  • Education – Ensure you have identified who in your community will be involved with ICD-10, from medical records to clinical to billing, and determine how much education they will need. There are many training resources available, from online resources to in-person training provided by state associations or individual consulting companies.
  • Resources – Staff responsible for determining ICD-10 codes should have coding references easily available. Many companies offer ICD-10 coding books in both paper and electronic format.
  • Know Your Software – For any software programs that obtain ICD-10 coding, check with your software vendors to see if they’re prepared for this change and what testing needs to occur prior to October billing. Many software vendors also have conversion reports available to assist with transitioning codes from ICD-9 to ICD-10.
  • Clean Up Your Records – Whether paper or electronic, clean up your code masters for current patients to resolve dates for any inactive diagnoses for that patient to ensure only truly active codes are converted during transition to ICD-10.
  • Start Coding – Prior to the change, staff should begin dual coding between ICD-9 to ICD-10 (although not on actual claims being billed) to ensure they are comfortable and ready for this change.

For more information, contact your BKD advisor.

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