13 Jul Will ICD-10 Coding help Outpatient Procedures?
The International Statistical Classification of Diseases and Related Health Problems (ICD) is now on its 10th revision. There are 68,000 Clinical Modification (CM) codes, and 76,000 Procedure Coding System (PCS) codes in the ICD-10 system. The ICD-10-CM codes are to be used for inpatient and outpatient diagnoses, whereas the ICD-10-PCS codes are used only by hospitals for inpatient procedures. Additionally, coders and billers use the Current Procedural Terminology (CPT) codes for outpatient procedures.
The Results of the 2012 MedPac Report to Congress
In 2012, MedPac conducted a study, and issued a report on Medicare Payment Policy. In 2010, the 4,800 hospitals in the Medicare system showed a 9% growth in hospital-based outpatient business. This contrasted greatly with the inpatient volume increase of only 2.7%. Today, outpatient visits make up over 31% of total hospital reimbursement. There are around 40 million people who do not have healthcare coverage in the United States, which means outpatient procedures will be more common.
The federal government did not change any billing requirements related to outpatient billing. However, some CPT codes used for outpatient billing are now required for noncovered entities. Based on medical necessity criteria, outpatient service reimbursements are restricted by Medicare, and if the diagnosis codes do not support this necessity, the entire claim could get denied. Hospitals and clinics should get the patient to sign an Advanced Beneficiary Notice (ABN) before the patient receives treatment or a service. This will allow the provider to bill the patient if the payer denies the claim.
Changes with ICD-10 and Outpatient Services
Outpatient procedures under the ICD-10 codes are not impacted directly, but there are some underlying changes required. The following factors affect ICD-10 outpatient billing:
- Instead of having 2 sets of documentation with dual code sets, the billing company should have standardization.
- Fewer mistakes occur given that ICD-10 procedures and diagnosis now demand more documentation.
- Cash flow loss is avoided as most payers require and reimburse based on specific CPT codes. This includes laboratory services, interventional radiology, and diagnostic tests.
- Use of specific codes and improved documentation will enhance data collection and be helpful for policy healthcare decisions and reforms.
- Payers will require submission of codes for claims processing, even though ICD-10 codes may not initially be required for outpatient procedures.
- High skill sets for the entire coding team is needed, regardless if the specialist is an inpatient or outpatient coder.
Reasons Hospitals Should Use ICD-10 for Outpatient Coding
The federal government plans to require dual coding in hospitals. This means hospitals will need to have two types of medical billers and coders: Those who know CPT coding, and those who understand ICD-10-PCS coding. Some industry professionals are making the case to code both inpatient and outpatient procedures using ICD-10-PCS. This means that CPT coding will phase out. The two basic concepts are:
- Standardized data for all procedures.
- Medical coders will have more scheduling flexibility.
While CPT codes are still being used, some healthcare payers are urging the government to change the guidelines. Healthcare payers are not the only entities with concerns. Some data collection agencies and medical registries may eventually require ICD-10-PCS codes. Outpatient coding productivity may decrease with this change, and continuing education and training will need to be budgeted. There is also concern about the increased documentation requirements associated with ICD-10-PCS.
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