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Will ICD-10 become just another reason for insurers to deny payment?

Fam Pract Manag. 2015;22(5):7

We are told that we need ICD-10 because ICD-9 isn't modern o r granular enough and is running out of space. We are told that we need ICD-10 for better quality reporting, public health research, health policy planning, fraud detection, and risk adjustment for quality based payments.

That all sounds reasonable. But will the primary beneficiaries of ICD-10 turn out to be payers rather than patients? Will ICD-10 be used as just one more tool to delay or deny payment to physicians?

Our own experts – see “Getting Ready for ICD-10: How It Will Affect Your Documentation” by Kenneth Beckman, MD, MBA, CPE, CPC, in our November/December 2013 issue and “ICD-10: Major Differences for Five Common Diagnoses” by Cindy Hughes, CPC, CFPC, in this issue – and many others keep warning us that ICD-10 requires more detailed and specific documentation to select and justify our diagnosis codes or we might not get paid. Some have even warned that insurers may not reimburse “unspecified” codes.

When I first read those warnings, they struck me as strange. Hospitals are often paid based on diagnosis, but family physicians are paid based on our evaluation and management (E/M) coding. An audit may reject our claims if our documentation doesn't support our E/M code, but I've yet to hear of a claim being rejected in my group because the doctor billed ICD-9 486, “Pneumonia, organism unspecified,” rather than 482.41, “Methicillin susceptible pneumonia due to Staphylococcus aureus.”

CMS's recent announcement that claims cannot be rejected during the first year for not being specific enough seems to support this fear that insurers could use ICD-10 to delay or reject claims.

Yes, in certain value-based payment situations, choosing a diagnosis code that doesn't fully capture the patient's complexity could indirectly lessen your reimbursement. But simply not getting paid for a less specific code is a different matter altogether.

There are plenty of reasons to be reasonably specific with our coding, such as better communication with other clinicians, better risk adjustment, and better population health management. But fear of not being paid should not be one of them. As physicians, we need to continue to make that point loud and clear.

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