Epic diagnosis coding changes have begun. This year, Blue Cross Blue Shield of Alabama tripled their diagnosis code request from four to twelve. Next fall, the entire U.S. healthcare field will shift from the 35-year-old coding system of ICD-9 to ICD-10.
The introduction of ICD-10 starts next October. It will expand diagnosis coding choices from about 13,000 to 68,000, not including hospital codes. “They’re more specific in nature,” says Mike Candelaria with MediSYS. “If you get injured in the abdomen, you’ll be able to tell in the coding whether it’s in the upper or lower quadrant, if it’s acute, if it’s temporary… and that’s across the board.”
“You can clearly see that ICD-9 has been outgrown just by the difference in the number of codes,” says Tammie R. Olson, CPC, CPCO, with Management Resource Group. “ICD-10 is going to provide a much more clear picture of what happened at each patient encounter.”
The Blue Cross coding change, though not so dramatic, could have a far greater impact on the bottle line of healthcare in Alabama. It stems from the federal Risk Adjustment Program. “We have been able to accept 12 diagnosis codes on a claim for several years but have not proactively requested additional diagnosis code information until now. This is largely due to the changes mandated under the Affordable Care Act, which established a plan for leveling risk among insurance carriers within a state,” says Koko Mackin with Blue Cross.
Insurance carriers must participate in the risk adjustment process beginning January 2014. The program transfers money made from premiums among insurers based on the complexity of their member populations. Basically, payments from carriers with healthy member populations will go to carriers with less healthy member populations. The additional diagnosis codes will help define those populations.
“In addition, if we are to maintain competitive premiums going forward, it is critical that we are able to accurately reflect the complexity of our member population to the federal government,” Mackin says. “We are encouraging physicians to include the diagnosis codes for all conditions assessed, treated or considered in their medical decision making for their patients.”
“That’s a big change for clients who are only used to coding based on the procedure. They’ll have to change their mindset,” Candelaria says.
Olson says this is likely just the beginning. “With the prevailing atmosphere centered on healthcare, we will continue to see changes to covered diagnosis codes from payer to payer,” she says. “Now more than ever, it is important that all payers be on the same page as far as coverage is concerned.”
Electronic health records (EHR) will be a real boon in this overhaul. “The Blue Cross change seems like a big process, but it’s more like us making a change in the software and then training clients,” says Jennifer Woodward with MediSYS.
When it comes to adding more diagnosis codes, many EHRs already show past diagnoses for a patient with just one click. It is the same with any chronic conditions. That allows physicians to easily see the codes that might be pertinent to the current visit and quickly apply them.
“It’s not necessarily that they’ll see dramatic changes in the look of the software. It’s more like them changing what they’re looking for in what’s already there,” Woodward says. From a billing standpoint, many EHRs build checks and balances at both ends — from initial input to claims submission, which will help with both the Blue Cross and the ICD-10 transitions.
Many EHRs also let users group together specific codes by treatment plan, tailoring it to their specialty or common practice treatments. “That could help with additional codes needed with Blue Cross, but it can certainly help with more accurate coding,” Woodward says. EHRs often display which diagnosis codes pay for the procedure entered by the physician.
Blue Cross says they’re working on various value-based payment programs to reward physicians for appropriately coding claims that help reflect the complexity of their patient population. “There also may be an audit function in the future, as our company is accountable for all diagnosis code information passed on to the federal government. We will be audited by the federal government on an annual basis,” Mackin says.
Management Resource Group’s Olson thinks the mammoth coding changes are good for the industry and the patients. “We were always supposed to code to the highest level of specificity. Due to the limitations of ICD-9, we have been allowed to use nonspecific codes, and this has allowed providers to become lax on their documentation, yet we were still being reimbursed,” she says.
The additional and more detailed coding will aid practitioners by helping to prove medical necessity. “It will force providers to improve their documentation, which should improve their reimbursement. We will see procedures that previously would have been denied by insurance companies, paid for,” Olson says. “It will also ultimately improve the quality of care given to each patient.”
