Transitioning Challenges Face many with Implementation of ICD-10

ICD 10 coding procedures were effectively initiated on October 1, 2015. For many, it’s about time that the United States medical system joined the rest of the world when it comes to coding practices. With its release, coding professionals can breathe a sigh of relief that the wait is over, but vast differences found between the two versions are causing confusion, frustration, and anxiety for many in healthcare.

During this transition, experts are expecting a greater number of denied claims to be bounced back to health care providers. What does that mean for you? Longer reimbursement time. More red tape. More phone calls and letters. More frustration.

Claims assistance professionals can reduce the number of denials of new claims filed after October 1, 2015 by organizing health insurance paperwork, reviewing claims for accurate coding, and directly deal with insurance companies and medical providers to ensure proper payment.

Why the change? Because after 30 years, medical treatments, knowledge, and technologies have advanced. The new coding procedures will enable doctors and hospitals to share more detailed information that ensures quality of care and plays a huge role in reimbursements for physicians and hospitals.

Over 100,000 new codes in ICD-10 provide challenges not only for billers and coders, but for doctors as well.

Bills with service dates after the October 1 implementation date must have ICD-10 codes or will be rejected or denied. Valid diagnostic codes will also be required in order to gain approval for many medical procedures and costly tests.

Brief history of ICD-10

A number of entities developed what was to become the International Classification of Diseases (ICD) starting in 1950, including the U.S. Public Health Service, the Veterans Administration, and Columbia Presbyterian Medical Center in New York. In 1966, the 8th version was published as the International Classification of Diseases, Adapted. Throughout the 1970s, other versions were published.

The World Health Organization (WHO) has been involved in creation of development of ICD publications since 1946 and helped develop the International Classification of Procedures in Medicine (ICPM) which was published in 1978. WHO was also involved with experimenting with alternative model structures for ICD-10.

The World Health Organization adopted ICD-10 in 1994. Since the mid-1990s and heading into the new millennium, a number of issues delayed the transition to ICD-10 in the US.

According to data gathered by the Workgroup for Electronic Data Interchange, delays have also affected readiness to implement the transition from ICD-9 to ICD-10. In March 2015, data was gathered among a small group of health care providers, health plans, and vendors. Less than one fourth of the physicians queried determined that they would be ready to implement ICD-10 by the October 1 compliance date. Approximately twenty-five percent claimed that they would be ready.

Ready or not, claims must be correct in regard to coding and accurate processing measures– if not, those claims will be delayed or denied.

Major differences between ICD-9 and ICD-10

Specificity is the name of the game with the new ICD 10 release. First, the basic and major differences between ICD-9 and ICD can include:

icd9 and ICD 10

In addition, codes for inpatient hospital procedures climbs from 4,000 to 87,000.

For example: a femur fracture using ICD-9 and ICD 10:

ICD-9 (Code 821.11) Open fracture of shaft a femur
(Number of codes for femur fracture? 16)

ICD-10 (S72.351C) Displaced, comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
(Number of codes for femur fracture? 1,530)

ICD-10 coding define injuries based not on type of injury, but anatomical site. In addition, E and V codes are incorporated into ICD-10, and new code definitions bring the codes into the modern era. Certain disease processes have also been reclassified to new sections or chapters that reflect up-to-date medical knowledge.

Help and solutions for the challenging transition from ICD-9 to ICD-10 are available through the Alliance of Claim Assistance Professionals (ACAP). Whether you’re a patient or a provider, call on the experts to help with your medical claim issues.

Mental Health Parity Still a Distant Wish for Most

Mental health parity remains a constant battle for young and middle aged populations of Americans seeking mental health services for drug and alcohol abuse, eating disorders, rape counseling, and posttraumatic stress disorders (PTSD). The challenges that such individuals face often go against insurance “standards” when it comes to provision of care. Unfortunately, when it comes to mental health and issues, the watchwords of most insurance companies still utilize the acute care standard – “if not suicidal, have to discharge”.

The Paul Wellstone Mental Health and Parity Act signed into law in 2008. The act sought to ensure that insurance companies treated mental health issues and substance abuse disorders on the same level as physical illnesses when a person’s insurance policy offers coverage for both. Since then the Affordable Care Act the mental health parity was extended to provide equal benefits with medical coverage, even for individual health insurance coverage.

Unfortunately, actual changes are not taking hold. Mental and substance abuse problems are still considered only on an acute care basis. Regrettably, such issues are often chronic in nature and necessitate long term management.

An alarming number of individuals between the ages of 20 and 30 are finding it increasingly difficult to obtain care coverage for mental health issues and related behaviors. County health services have begun to develop “transition programs” but in some areas, a four plus month wait or longer is typical. Individuals, including those dealing with PTSD, substance abuse, and eating disorders, are either being denied access to such care facilities or are being discharged from their treatment programs early. When an individual’s treatment courses are cut short, they often return home with ineffective coping skills that lead to relapses and in some cases, death.

60 Minutes recently ran a story related to denial of mental health coverage by insurance companies despite doctor’s prescribed orders for treatments of mental health and addictive behavioral issues. In fact, the exposé noted that many insurance adjusters “aggressively” review not only chronic cases, but long-term mental health care needs. Most health insurance companies often deny coverage for full treatment care plans, cutting off benefits at the halfway point.

In an attempt to enhance mental health treatment opportunities, the Affordable Care Act has shown significant improvements for those seeking care in physician and therapist office settings. Unlimited visits are a definite improvement for those with manageable mental health problems. Unfortunately, for those needing intensive outpatient or inpatient services, the quality of care and the number of in-network providers are limited.

Most reputable mental health treatment centers are out-of-network, placing a significant financial burden on patients and their families. Many of these patients are young adults still in college or high school, which creates a volatile situation within the family dynamic. Young adults often blame parents for their substance abuse; divorce, neglect, emotional distance are just a few reasons. Yet most parents paying for their children’s treatment don’t share this blame.

In today’s healthcare economy, insurance companies are the ones who determine duration of treatment, which makes it extremely difficult not only for patients to receive the care they need, but for patients and family members to struggle through the requirements and demands of filing claims, billing and reimbursement for such services.

Real solutions are only possible with genuine consideration from insurance companies. The Alliance of Claim Assistance Professionals (ACAP) strongly urges our readers to file appeals on all levels, as ACAP experience tells us that meaningful review takes place at the Departments of Insurance levels. Significant change will only come by filing mental health denial appeals to state insurance departments.

The Specific Question

During medical emergency or urgent situations all we really want is proper medical and timely care. We assume that the hospital and doctors will do the right thing. That is to take our insurance and don’t overcharge us. Fortunately, it does happen that way most of the times. Then there are some times when we assume taking our insurance means they are participating in our insurance network. Unfortunately, that is often not the case. Taking our insurance simply means that the hospital or doctor will bill our insurance. If they get any payment it will be deducted from their total bill and send us the balance due.

If you are unsure the specific question to ask is exactly this: Are you a participating provider in my insurance network? To your surprise the answer to this question may be this “ I don’t participate in any insurance network.” So the next reasonable question will be: how much do you charge for this service? I am willing to bet that most doctors, and even hospitals will not give you an answer. They simply don’t know.

You want to ask: how can that be?
The answer is rather simple. In the case of a hospital the clinicians simply use an internal billing code, that is often not a code for the actual procedure; it is simply a computer system code that transfers into insurance procedure code a few days later in the computer software.
In the case of doctors, the billing company or office does the billing. The doctor may even know the actual codes and charges, but in most cases they will not disclose that information to the patient.
At this point the best one can do is getting a promise from the doctor that his or her changes are reasonable to our services.

Of course planned visits, such as office consultation, radiology services, or surgery can be financially pre arranged. It does take some work, and often putting a pressure on each party. A person need to get a CPT (procedure code), and diagnosis code from the doctor’s office. Then provide that to the insurance company and request the allowed payment amount from the insurance. Some will give it just for asking, while others have to be pressured to do so.