New Codes, New Rounds of Rejections

Oct. 1, 2016 brought a very large update to our ICD-10-CM coding system, as everyone is well aware. There were many new codes. Codes that existed in the previous system but lacked specificity were deleted and new codes with much higher levels of detail were added for us.

Many of the conditions that physicians treated that were missing laterality were changed to add it, and many that were missing a bilateral option had that added into the coding system as well.

Overall, the code changes brought many of the missing condition codes we were hoping for – for example, we were all glad to see codes for overexertion restored.

But with these codes came new rounds of rejections. Some policies no longer matched up with the diagnosis codes. These policies mismatched correct diagnosis codes that should have been associated with the clinical condition found in the policies, creating financial distress and frustration in many of our practices. 

These issues took months for most practices to get worked out. In ophthalmology, we were hit pretty hard. The new combination codes for diabetic ophthalmology conditions didn’t match up with current medical policies. I started to get a lot of calls from not only medical practices, but also from other organizations whose members were experiencing denials. The first question everyone asks is: what am I supposed to do? Most claims were reprocessed without additional work from the practice, but it caused significant revenue stream issues. And it left physicians feeling jaded. If they had just defaulted to unspecified codes, they would not have seen many of the issues.

It’s hard to have a conversation with a practice when you must say, “code to the highest level of specificity, even though right now you won’t get paid for it,” when everyone involved wants to get paid quickly. And many don’t know who to turn to in order to get their problem resolved.

There were some practices that simply thought they could no longer get paid for some services. That’s extremely harmful to a practice, many of which are without certain resources or skills that could help them determine what to do next. But my advice is this: please don’t ignore it or write it off! Follow these steps for help:

  1. Make sure someone understands the rejection – was it for an NCCI edit, modifier edit or diagnosis issue, etc.? Look at the reason codes.
  2. Read current health plan communications; they are usually good at telling you when they are making changes.
  3. Read current policies regarding the condition to see if any changes were made.
  4. Call your provider rep for help.
  5. Look at resources available to you, such as state medical societies and specialty societies.

If there have been no changes and the diagnosis is missed in the policy but should clinically be there, reach out to the relevant payer so that it can investigate and make changes. This is a good time to employ your specialty society or your state medical society to help as well.

For example, in one ophthalmology policy, cancer of the left eye was included, but the right eye was missed in the policy. This is an error that can be quickly identified and fixed.

The problem becomes the amount of time it takes to then get payment. Sometimes it can be 90 days or more, which for some specialties can be very problematic if you are seeing large numbers of patients with insurance. The key to diminishing the impact is quick detection; make sure you have someone watching your acknowledgment reports on claim submissions. It is always your first line of defense. 

Another strategy is to watch for the draft policies that are out for review. If it is going to affect your practice, then you should be sure to review so you can find and fix any potential problems before the policy becomes final.

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