ICD-10 impacts to providers – Scheduling : Preauthorizations and Certifications

ICD-10 impacts to providers – Scheduling : Preauthorizations and Certifications

Does your organization have Standard Operating Procedures (SOPs) that use ICD-9 CM diagnosis or ICD-9 procedure code information?  If so, those procedures and systems need to be evaluated as part of the ICD-10 Impact Assessment.

In medium to large, multi-site health systems, a centralized scheduling team responsible for scheduling the majority of the diagnostic services and the pre-testing for OR cases often performs this function.  Phone calls and faxes with patients and physician offices are coordinated.  AT the point of scheduling the scheduling team collect the basic patient information and test specific information as determined by the department.   Scheduling software usually has a menu of services used to schedule and often the diagnosis description at the time of scheduling is collected.  Once the test is scheduled the account is passed to pre-registration.

If in this process your organization uses ICD-9 diagnosis codes as a required component of the patient intake, those systems and processes must be remediated.   Recently we spoke to an outpatient facility that does just that, assigning the ICD-9 CM diagnosis code BEFORE the physician encounter.  In fact for this particular provider, the physician was not able to assign a diagnosis code in the EHR at all!  This would not only be an ICD-10 unfriendly approach in terms of process and electronic health record clinical documentation, but one that could open the organization up to RAC audits and less than desirable documentation of medical necessity for determining the viability of a health care claim.   Utilization management departments of health plans use such data in medical records requests to determine whether a claim should be paid and what portion, if any should be paid.   Therefore this component of the ICD-10 assessment is important as it has revenue cycle impacts.   A failure to remediate this issue would also compromise ICD-10 data quality going forward.

Often this type of information is buried in your organization and it is important to find all such cases.  Large health systems may have 200 to 300 discrete systems, both off-the-shelf and custom built.  It is not unusual for at least 1 in 5 of these systems to be impacted by ICD-10

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About the Author:

Michael is Managing Partner & CEO of No World Borders, a leading health care management and IT consulting firm. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $4 billion in healthcare mergers and acquisitions. Education: UC Irvine – Economics and Computer Science, University of Southern California – Business, Stanford Medical School – Biomedical Informatics, Harvard Law School – Bioethics.

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