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Costly ICD-10 Traps and How to Avoid Them

Don't fall into a costly ICD-10 trap. Luckily we have created a guide for you to help you avoid these costly ICD-10 traps. Click here to learn more.

Courtney Lefferts
5 min read
August 26, 2015
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Imagine you’re playing a game. More specifically: an ICD-10 Rube Goldberg-style game. To win, you have to scurry through a series of stages without getting caught in costly traps. But what happens when you find yourself at the mercy of the swiftly-turning plastic crank? Before you know it, the cage has lowered and you’re out of the game—forever separated from your cheddar. Okay, so ICD-10 isn’t a game of zany action on a crazy contraption, but if you don’t have a strategy, you might end up feeling like you’re stuck in a mouse trap—with your hard-earned cheddar (i.e., money) just out of reach. Don’t let costly ICD-10 traps force you out of the game. Here’s how to come out of the ICD-10 transition as a winner:

The Trap

Ignoring the Risk

ICD-10 is right around the corner, and with its implementation comes an entirely new way of coding. This new coding methodology requires providers to use clinical expertise to nail down the most accurate and complete codes. And when it comes to drilling down to the proper code, if you believe your software—or cheat sheet—will offer you everything you need, you’ve fallen for a trap. Furthermore, ignoring the risks associated with throwing your judgement out the window can land you in hot water (and without payment). Ultimately, failing to prepare will result in lost productivity, revenue, and even morale. And when times get tough, your team needs a game plan.

The Escape

Preparing Now

Hopefully, you’ve already prepared yourself and your staff for the transition. But if you haven’t, the only way you can avoid the costly trap of relying too heavily on outside sources is to start preparing internally now. According to CMS, here are five ways you can get ICD-10 ready:

  1. Make a plan.
  2. Train your staff.
  3. Update your processes.
  4. Talk to your vendors and payers.
  5. Test your systems and processes.

Although some of these steps are time-consuming, there’s no need to panic. Remember, some prep work is better than none at all. Any preparation you do now will help you reduce lost revenue in the future.

The Trap

Using Unspecified Codes

Are you in the habit of using unspecified ICD-9 codes? This crutch won’t fly with ICD-10, because if there is a more specific code available and you fail to use it, you could receive a claim denial. So, what should you do?

The Escape

Thinking in Terms of ICD-10

According to this Medscape article you should, “Drive out unspecified diagnosis codes in ICD-9. These are codes that are listed as not otherwise specified (NOS), many of which end in .9. If you make an effort to stop using them in your current system, there will be fewer queries with the implementation of ICD-10.” By fixing these errors now, you’ll have more success with ICD-10 coding.

The Trap

Dual Coding

When it comes to dual coding—especially with claims spanning the October 1 date—you’ll have to make the correct decisions to avoid denials. When deciding whether to use ICD-9 or ICD-10 codes, here are several questions you should ask yourself:

  • Is the date of service on or after October 1?
  • Are all of my payers transitioning to ICD-10?
  • How do I properly split claims?

The Escape

Coding for Dates of Service

Coding based on date of service—not date of submission—is crucial. All claims with dates of service on or before September 30 should contain ICD-9 codes. All claims with dates of service on or after October 1 should contain ICD-10 codes. So, that should bring some clarity to these uncertainties. But what about your workers’ comp and auto insurance payers? Some of these non-HIPAA-covered entities may choose not to switch. For that reason, you’ll need to contact all of your payers directly to find out whether they plan to transition.

Furthermore, you’ll need to take extra care for claims that span the actual transition date. For example, CMS requires that, “...when claims are split for an encounter spanning the ICD-10 implementation date, you must maintain all charges with the same Line Item Date of Service (LIDOS) on the correct corresponding claim for the encounter. You must not split single item services whose timeframes cross over midnight on September 30, 2015, into two separate charges.” This is just one example, as each payer will have its own specifications on how you should handle such claims.

The Trap

Relying on the CMS “Grace Period”

Think the CMS “grace period” will grant you unconditional payments in the post-ICD-10 world? Think again. First, this grace period only applies to Medicare claims. Second, you still must use a valid code within the correct family of codes. So, if your coding selection is totally off, you’ll receive a denial. Finally, you must learn how to code accurately using your clinical judgement. Delaying this process will only come back to bite you further down the road.

The Escape

Coding Accurately

What’s the remedy? Start transitioning to the ICD-10 mindset now. You’ll need to ask yourself questions about each one of your patient’s injuries so you can come up with a complete condition description (including laterality, phase of treatment, and any external factors). Additionally, you should start documenting to support more specific codes now. Come October 1, you’ll be a pro at supporting the medical necessity of your services through your code selections. Want to learn more about coding for medical necessity? Check out this resource.

Whether you have two to four players, are more of a Candyland fan, or hate playing games altogether, don’t let yourself fall into any of these costly ICD-10 traps. Want more ICD-10 information? Well, you’re in luck. Stay tuned to the WebPT Blog as we cover everything ICD-10 to help you through the transition.


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