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Oct 17 2011   12:19PM GMT

Claims submission and ICD-10: 6 key focus areas for providers

Posted by: Jenny Laurello
Baskar Mohan, ICD-10, ICD-10 migration, ICD-10 transition, ICD-9

Guest post by: Baskar Mohan, Director, Healthcare Practice, Virtusa Corporation

The Health care industry as a whole is undergoing a transformation influenced largely by technology advancement, strong macro-economic factors and regulatory mandates such as ICD-10. Providers are left in a tight spot, where they have to comply with the requirements of Medicare and Medicaid (depending on the hospital, this can be up to 40% of total revenue), HIPAA regulations and State and Central government policies. I will be focusing on the HIPAA regulations, in particular the ICD-10 changes. These changes will have the most impact on both the top line and bottom line revenue.

ICD-10 touches upon every aspect of a provider organization; from the time the patient enters the facility, until the time the provider has actually paid for the services performed. This cycle time typically varies anywhere from 30 to 90 days depending on the duration and complexity of the service. Revenue Cycle Management forms the crux of this process and is the most impacted area of ICD-10. Providers invest millions of dollars every year in maintaining and updating these systems. Let’s look at some areas within the revenue cycle that if managed effectively will result in the accuracy of claim submission process:

  • 1. Patient Diagnosis – Detailed information has to be captured to ensure all possible diagnosis have been documented. Physicians should be made aware of the new ICD-10 code implications and should be guided to provide accurate information for efficient backend processing.
  • 2. Patient Procedures – Physicians should decide what’s best for their clients. Information on the procedure that will be performed should be readily available for the accuracy of the ICD-10 codes. The procedure codes have increased from 4,000 to over 80,000 in ICD-10-PCS.
  • 3. Preauthorization – As payers look for ways to cut costs on the provider fraud and abuse, they have started requesting prior authorizations for more procedures. Because of this, it’s the responsibility of the Provider to obtain prior authorization before performing the procedure.
  • 4. Patient Discharge Summary – The patient discharge summary is an important component of the billing process. All of the information collected up to this point is now ready for coding and creation of the claim. Providers will need to invest in rule-based applications to perform all the required validations before moving to the next step.
  • 5. Patient Record Coding – Now that we have a clean patient data file, the stage is set for the coding process to begin. Based on the provider this process is typically carried out in a few different ways including automatic coders, manual coders or clearinghouses. Again, rule-based applications validate the accuracy of the coding before the final bill is ready to be generated.
  • 6. Patient Bill/Claim Submission – During this stage the patient bill is created, along with the electronic claims, and then submitted for payment. These documents are run through a set of HIPAA validations to ensure compliance with the format requirements.

Given that the deadline for ICD-10 migration is two years away, provider organizations still have time to plan ahead  to ensure stakeholder satisfaction and  profitability. I would love to hear your thoughts and experiences while implementing the ICD-10 programs. Please share your comments below.

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