The flexibility offered during the transition to ICD-10 coding disappeared as of October 1, 2016. Now, all providers need to precisely reflect clinical documentation per the coding guidelines and assign codes to the highest degree of coding specificity. A lack of documentation supporting the code can lead to the dreaded claim denials.
The Impact of Claim Denials
Not only can claim denials severely impact your bottom line, but handling them is time consuming, labor intensive and can rupture patient relationships. All denial fixes occur after the claim has been processed and the damage done.
Proactively Dealing with Claims Denials
A proactive approach to eliminating or at least minimizing claim denials is to consistently follow a pre-bill management process which can be effective at catching some potential denials. Coupled with analytics, a simple yet effective pre-bill process is the start to mitigating denials and the headaches that accompany them. Good analytics stem from continually probing for who, what, when, where and why to detect the root cause of claim denials. Use analytics to chart trends and denial types such as coding miscues and missing documentation.
Preventable Denials
Industry statistics suggest that 90% of claim denials are preventable and 67% are recoverable while as many as 65% of denials are never reworked.
Often, denials occur from deficient documentation from the patient consult, the time when interventions and diagnoses need physician substantiation to ensure compliant coding. Even then, pinning down the cause to a problem can be a slippery process. For example, sometimes providers chalk up denied claims to subpar coding when the true root cause was incorrect patient demographic information collected during the admission or registration process.
Tips to Catch Preventable Denials
Monitor the top 25 ICD-10 diagnoses rather than only denied claims. This can further be analyzed by volume and revenue generated (or lost).
Develop a pre-bill edit list for an additional level of supervisor review.
Continuous clinical documentation improvement strategies with providers to identify documentation-related issues requiring additional education/information.
Verify claims billing system upgrades and reset automated payor billing edits.
Enforce ICD-10 specificity.
Embed monitoring and auditing ICD-10 coding into the practice.
Utilizing computer assisted coding (CAC) to promote compliant coding rooted in the integrity of clinical documentation. However, final code selection is to be based on coding guidelines, clinical documentation, and compliance protocol.