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Avoiding Audits: How to Ensure Your ICD-10 Coding Practices are Accurate

by Marissa Sanchez on March 30, 2017 at 1:38 PM


Due to increasing and changing regulations, many providers know all too well the challenges of staying up-to-date while worrying about the threat of a potential audit. After nearly a decade under ICD-9, most practices have focused intently on getting ready for the new ICD-10 coding standards over the past few years. The industry watched closely amidst concerns that coders could maintain speed while remaining accurate with the new set of codes and that provider clinical documentation would be able to support high-specificity claims.

Most payers, including the Centers for Medicare & Medicaid Services, or CMS, allowed for a one-year grace period in which the industry could code to adequate specificity as long as the correct category and laterality were reported.

On October 1, 2016, the period of flexibility lapsed. Claims are now supposed to be submitted with diagnosis codes at the greatest specificity appropriate. So this year, after the expiration of the ICD-10 grace period, finally reflects how the transition to high-specificity coding will truly affect claims processing, payments and provider audits.

Related: Are you worried your coding processes are undervaluing your practice services? Check out our webinar specific to the ICD-10 code set.

What does this mean for you as a provider?

Now that the ICD-10 grace period is over, coding guidelines require all claims be coded to the highest level of specificity possible. As such, providers are expected to already be using the most detailed code available based on their clinical documentation. Since the flexibilities expired, CMS review contractors are now able to use coding specificity as a reason for denial and justification for an audit on claims. Unspecified codes are still listed in ICD-10 2017 and can be used when information in the medical record is insufficient to assign a more specific code. However, they should not be used as a catch-all for patient encounters that are not documented properly.

Providers should review the sections of ICD-10 that directly affect their specialty and ensure their clinical documentation includes all necessary information to support the diagnosis and subsequent claim. Sub-par clinical documentation puts practices at greater risk for an audit. The burden falls on both provider and coder to ensure ICD-10 coding compliance.

Internal auditing and monitoring is a vital part of compliance programs in medical practices, hospitals and other healthcare entities. If you don’t have the necessary staff to conduct an internal ICD-10 assessment, hire a consultant or auditor who specializes in your payer mix or specialty to identify errors and missed opportunities for high-specificity coding. Be proactive instead of waiting for a payer request or an increase in denials to start evaluating your ICD-10 coding and clinical documentation.

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This post was written by Marissa Sanchez

Marissa Sanchez is a client services manager at Intermedix. She has over 9 years of healthcare and customer service experience. Marissa obtained her degree from Cerritos College.

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