With ICD-10 coming in 111 days, as a patient I start to stress out about how it might impact me. A physician once told me that “90% of physicians are already doing the required ICD-10 documentation, but they just need to add laterality in order to be more specific”. Sounds simple, but is this statement truly accurate? And if not, what will the downstream impact from a patient’s perspective?
Let’s deep dive into the patient experience in the current ICD-9 world. A simple health maintenance exam with vital signs (pulse oximetry included) and a urine dip would generally be covered by many insurers. In the ideal world, this occurs without any added hassle to the patient, but what if the urine dip is “abnormal” and gets sent for a culture with an ICD-9 code of V70.0 (Routine General Medical Examination)? The culture likely won’t be covered and the patient may eventually receive a bill for services that otherwise would have been covered by the insurance company had the test been associated with the correct supporting diagnosis. A patient without insight into medical billing may just pay out of pocket without further research into why the services were not covered by the insurer. In some cases however, a patient with a medical background may be savvy enough to recognize the problem was related to an incorrect ICD-9 code assignment. Given the abnormal urine dip, the culture should have been billed with a problem code and not a health maintenance code. Had this been done, the patient may not have been responsible for the entire balance of the culture. The patient in this example notified her provider’s office of the problem, and even explained to the billing personnel how to fix the problem. Six months later, she was still stuck in the midst of what I will label as “healthcare gridlock”. The insurance company would pay for the culture if a problem code were submitted, but the billing office couldn’t change the code without the doctor first adding the appropriate documentation to the record.
If provider documentation isn’t clear and concise enough to get to an appropriate ICD-9 code now, then fast forward to October 1, 2015 when ICD-10 is relevant, who suffers? Sure the provider’s office will not receive adequate payment (or none at all) for services rendered, but will the patient be left to pick up the pieces? If we can’t get it right in ICD-9 (and the aforementioned scenario seems to happen far too often) then how are we so confident that those 90% of providers will get it right in ICD-10? Rather than assuming that risk and potentially putting patients in difficult financial situations, wouldn’t it be helpful to add prompts to your existing EHR so that providers are clear on what MUST be documented to reach an appropriate ICD-10? With all of the initiatives and mandates that providers are subjected to these days, we can help ease their transition to ICD-10 by customizing your EHR templates to support thorough and efficient ICD-10 documentation workflows.
When all is said and done, if it isn’t correctly documented, then it wasn’t done (at least that is what a coder might have to assume) and chances are that the patient will have to eat some portion, or even the entirety, of the bill. With Galen’s Clinical Documentation Improvement service offering, our goal is simple – to make sure your organization is well prepared for ICD-10 so you can get paid and patients do not have to suffer. If you have any additional questions about ICD-10 readiness, please feel free to contact us.