Since going into effect on Oct. 1, 2015 ICD-10-CM will not just require doctors and other health care providers to be more detailed and accurate in their coding for services they provide. It will also up the ante of health literacy expected of patients.
Why ICD-10 Will Up the Ante of Health Literacy
The new coding system increases the importance of patients providing more accurate and detailed information about their health and events leading up to medical encounters than did the previous system. The reason is doctors and other health care providers will have to use many more codes that are more specific when they bill for their services.
Those encounters for which health literacy will be most important are initial ones with new doctors and those for new health problems. New doctors often do not have complete records and all of the diagnoses related to a given visit. Even if they do, some of the diagnoses under the replaced ICD-9 coding system are different under ICD-10-CM. New diagnoses made based on information patients provide rather than the physical examination and tests generally require greater health literacy for accuracy.
The impact ICD-10-CM will have on claims adjudication
Claims adjudication is the process by which an insurance company decides if it will pay for billed services provided to one of its members. The initial stage of the process is the computerized matching of service codes with diagnosis codes. Service codes are CPT codes. Diagnosis codes are ICD codes. ICD-9-CM was the coding system prior to ICD-10-CM. The matching of the service and diagnosis codes is the means by which insurers determine how much they will pay or if they will pay a claim at all. Health care providers use CPT codes to tell insurance companies what service(s) they provided. They use ICD codes to explain the reason for the service(s).
One of the problems that will exist with ICD-10-CM is the confusion resulting from the inconsistency and differences between health insurers with respect to their rules for processing and paying claims under the new coding system. The fact that insurers don’t publicly publish those rules might compound the problem.
The effect of coding mismatch on reimbursement
Mismatch between the actual diagnosis and service performed is one of the most common reasons for claims denials. Based on the report of one expert group, the current percentage of claims denied on first submission is 3.8%. Many expect that figure to surge with ICD-10-CM because of more frequent mismatching of codes and other coding errors. The Centers for Medicare and Medicaid Services (CMS) have gone so far as to state that the claim denial rates might skyrocket by 100% to 200% in the early stages of the transition.
Payment denials could result from using incomplete codes or codes that are not specific enough. Incomplete codes are those that require one or more additional digits or an additional code. Codes that are not specific enough are those listed in the ICD-10-CM coding manual as unspecified codes.
Under ICD-9-CM diagnosis code mismatches did not affect reimbursement for primary care services to the same degree as for specialist visits and certain high dollar procedures such as MRI scans. But the effect will most likely be greater across the board with ICD-10-CM.
Other consequences of improper ICD-10 coding for providers
Another problem will be denial of precertification (prior authorization) if health care providers don’t disclose an acceptable ICD-10-CM code to justify a planned service(s). Such denial will serve as forewarning that the insurer will not pay for the service(s).
In addition to causing reduced payment or non-payment for services, the use of unspecified codes if excessive, can trigger the audit of a medical practice or other health care facility. Depending on the results of the audit, a healthcare plan might terminate a provider or request monetary paybacks.
A doctor or other healthcare provider might avoid payment denials and audits by always using specific diagnosis codes that match the services provided. But if the medical record information (medical documentation) does not justify the use of a code(s), that strategy is fraud and could have far graver consequences than an audit or denial of payment. After all, fraud is deliberate deception to acquire an unlawful benefit. The use of a diagnosis code without sufficient documentation is the deception. Receipt of payment for the medical service is the unlawful benefit.
Because of the increased number and level of specificity of the codes within the ICD-10-CM coding system, it is reasonable to presume that the fraud cops are in full force. Ignorance might be bliss, but probably won’t be merciful.
How Improper ICD-10 Coding Can Affect Patients
At this point you might say – “So my doctor didn’t get paid – That’s not my problem.” Well – if your insurer denies payment for service you received because of a CPT/ICD-10 coding mismatch it considered that service to have been unnecessary and therefore a non-covered benefit. In that case, you are legally responsible for paying for that service. Moreover, it will not apply towards your annual out-of-pocket expenses because it was a non-covered service. Such is the case even though the Affordable Care Act limits for 2017 are $7,150 for individuals and $14,300 for families covered by individual health plans.
A patient might argue that because the doctor’s office did not use the appropriate ICD-10-CM code – “I should not be responsible.” If the medical documentation shows that the doctor made a reasonable effort to obtain the necessary information for proper coding, but the patient could not or did not provide it, holding the patient responsible is fair and just. A hypothetical example is the following:
During the initial evaluation of a new patient the doctor detects a very slow heart rate. The patient informs him that a previous physician in a different state from which she relocated evaluated and diagnosed the problem. But she could not remember any details about the evaluation or the diagnosis. Of note is the fact that the prior doctor closed his practice abruptly and cannot be reached. The new doctor orders a 24-hour heart monitor test (Holter monitor) and refers the patient to a heart specialist.
Because neither he nor the patient knows the cause of the slow heart rate the new doctor uses an unspecified ICD-10-CM code for bradycardia when ordering the heart monitor study and referring to the specialist. The insurance company denies payment for both services because of the use of the unspecified ICD-10-CM code. Of note is the fact that the Holter monitor performed at a time when the patient did not have any symptoms was normal.
The patient later finds out that the previous doctor had diagnosed sick sinus syndrome as the cause of her slow heart rate based on an abnormal Holter monitor done at a time she was experiencing symptoms. By the time that information is passed on to the specialist in the Holter monitor department of the local hospital it is too late for them to rebill for their services using the more specific ICD-10-CM code. The patient is therefore responsible for both charges.
Holding a patient responsible for payment of services not covered due to improper ICD-10-CM codes resulting from patient inability to provide the necessary information might not be the only consequence of the new coding system. It might become commonplace for doctors to use health literacy as a criterion for deciding whether or not to assume the responsibility of care. Some practices might require patients to sign a contract agreeing to work toward improving their health literacy. One might consider either strategy to be a form of cherry picking, but both have some merit.
Lastly, improper use of ICD-10-CM codes could lead to the disruption of a patient’s continuity of care because of the need to find a new doctor. That need could result from a breakdown of rapport stemming from the unpaid debt. Additionally, a physician might have to close his office because of cash flow problems due to multiple claim denials, termination from an insurance program(s), or criminal indictment for fraudulent billing.
Health Literacy and ICD-10-CM Preparedness
Physician preparedness for ICD-10-CM includes a staff properly trained under the new coding system, the right electronic health record (EHR), updated billing software, revised super bills, and other measures to ensure the proper entry of correct codes. These steps are important and necessary backend measures. But they don’t address the need for front-end preparedness.
Front-end preparedness is a state of readiness that ensures the acquisition of reliable and accurate information as the basis for medical documentation to justify the use of some of the ICD-10-CM codes. In some instances the physical examination and basic testing provide all the information needed. In other cases, such as the hypothetical one discussed above, subjective information (what the patient tells the physician) is most important.
This patient-driven aspect of the ICD-10-CM billing process is what will significantly raise the stakes of health literacy in the post ICD-10-CM era. The reason is patients, residential caregivers and healthcare proxies will need to be able to obtain, understand and utilize basic relevant health information to make good decisions that promote accurate and appropriate medical documentation.
Hence, ICD-10 health literacy is not a future concept. The conception has occurred. The expression of those decisions driven by ICD-10 health literacy will be the information conveyed to healthcare providers during visits. Regardless of the front-end strategies for dealing with ICD-10-CM, ICD-10 health literacy is also important.
During encounters with patients, doctors and other healthcare professionals analyze information obtained from patients in conjunction with findings on physical examination and test results. They then decide based on a comparison of that information which one of two or more diagnoses is the most likely cause of a health problem. Doctors refer to this process as the differential diagnosis.
In formulating a differential diagnosis doctors ask patients pertinent questions based on their professional knowledge of various diseases or conditions that the patient might have. For different reasons though, some questions may not get asked, especially in real time. That is when a patient’s knowledge and understanding of a health condition(s) is invaluable.
Here’s a hypothetical example. During an office visit for chest pain a patient without the need for questioning informs the doctor that physical activity and emotional excitement bring on the pain. He describes it as squeezing. He states that it tends to radiate into his left arm and jaw. He reports that it has been occurring for three weeks but is increasing in frequency. He notes that one nitroglycerin tablet placed under his tongue used to relieve it but he now has to take three at five minute intervals to obtain relief.
Because of that patient’s awareness of what was important to tell the doctor and the doctor’s differential diagnosis a red light immediately comes on. The doctor appropriately hospitalizes the patient for unstable angina using an ICD-10-CM code for that diagnosis as the reason for the admission. The doctor’s office and the hospital bill the insurance company using the same code and there are no problems with payment for services. If on the other hand the patient had been vague in describing his pain it would have had been more appropriate for the doctor and hospital to use an unspecified code for chest pain instead of the more specific one for unstable angina. Use of that code though would have increased the likelihood of the insurance company denying payment of both claims.
In the above hypothetical example, the patient not only decided what was important to tell the doctor. He utilized his understanding of coronary artery disease to help his doctor make an accurate and timely diagnosis. He probably obtained knowledge and understanding from reading and possibly asking questions. He also retrieved information pertaining to the increase in the frequency of his chest pain and the requirement for increasing amounts of nitroglycerin to relieve the pain from either his memory or a log which he kept and brought to the office with him.
A Proactive Consumer ICD-10 Health Literacy Action Plan
ICD-10 health literacy is not patients learning ICD-10 codes. It is being able to obtain, understand and present information to healthcare providers which aids in the medical documentation which justifies their use of the codes. A viable action plan should include a means of obtaining, understanding and utilizing health information to achieve that goal whether it is for yourself or someone you help care for. A suggested action plan is as follows:
- Find reliable and authoritative sources of health information, whether they are online, in hard print, or both. The format can be text based, audio based, video based, or a combination of either.
- Obtain information that builds knowledge about health conditions or issues pertaining to you or the one you are caring for. If the plan is for yourself focus on conditions that you currently have or are at risk of developing based on your family history or certain risk factors such as smoking, obesity, diabetes and high blood pressure.
- Focus specifically on information that helps in communicating to a doctor or other healthcare provider clues of a change in your health, particularly signs and symptoms. It might require learning about some of the common signs and symptoms of a condition(s) you may have or are at risk of developing.
- Learn about the staging or classification (if applicable) of any disease you or someone you are caring for has. Find out and record the stage or class (if applicable). The stage or class of many diseases determines which ICD-10-CM code should be used. Update the record as changes occur.
- Ask your doctor for answers to questions you can’t find doing your own research. Take notes when your doctor answers your questions or gives you other important information pertaining to your health, including test results.
- Devise a system for recording, tracking and storing important data about your health. That data should include signs, symptoms, diagnoses, surgeries, procedures, important test results and answers to questions you ask your doctor. The system might be a personal health record, medical diary or a collection of cheat sheets.
- Periodically review and update your data as it changes. Review relevant data prior to doctor visits. Take relevant data to your doctor’s office during visits if you have difficulty remembering it or if showing it is a more efficient way of presenting it. Decide based on mutual preference whether to convey the information to your doctor via electronic health record portal; fax machine; regular mail; or e-mail. Realize that e-mail is the least secure of the methods.
A proactive ICD-10 health literacy action plan is not just a strategy for preventing or minimizing payment problems that may occur following the changeover in the coding system. It should work hand-in-hand in promoting patient engagement in health care – a tenet of health care reform.
According to the American Medical Association poor health literacy is a stronger predictor of a person’s health than education, age, income, race, or employment status. It is therefore reasonable to presume that ICD-10 health literacy will improve health care and health care results. Its significance is not just in the future. It’s now.