July 14, 2016
Michael Damrich

Background: On October 2015 when ICD-10 debuted across the US, the medical industry held its breath. Volumes of literature had been written surrounding the financial strains ICD-10 was going to bring with it. To assist with the transition CMS introduced “…a ‘grace period’ during which physicians will not be penalized for errors.” Effectively, Medicare claims are not denied during the October 2015 – October 2016 year for lack of ICD-10 specificity, providing the ICD-10 code is associated to the correct family of codes. Some private payors (Aetna, Anthem, Humana, Kaiser Permanente and United Healthcare) opted not to follow suit. As the “grace period” was not Congressional legislation, there is no uniformity between CMS and commercial payors on this issue.

Today: Submitting Unspecified .9 ICD-10 diagnosis codes (depending on the payor) has resulted in inaccurate reimbursement and/or often denied claims—at the very least. After the Grace Period ends a few months from now, there may be penalties. For those who have scraping by meeting the minimum requirements in ICD-10, you will need to make changes now to be ready for October 2016.

ICD-10 Success During ‘Grace Period’ May Not Predict Long Term Success

Jon Tulloch, Executive VP of Sales at Vincari said many practices have associated their success of ICD-10 based on the “Grace Period.” Medicare claims are not currently denied as long as the submitted ICD-10 code is within the appropriate family of codes. “Some facilities are meeting the minimum requirements to submit a bill, leaving a lot of missed potential to increase reimbursements.  Strictly speaking, those facilities who fit this category are not ICD-10 compliant,” said Tulloch.

The long-term risk of submitting unspecified .9 codes is more cause for concern. Physician compensation has shifted from fee-for-service to value-based payment. Financial reimbursement is tied to actual patient outcomes compared to expected patient outcomes. Payers want to know the granular diagnosis data for their insured patient population. To achieve this providers are required to document the true burden of illness in order to avoid being penalized with a reduction in compensation.

Vincari Users Are Not Using Unspecified Codes

Vincari’s Lightspeed Valet ensures ICD-10 specificity, eliminating the need for coders to resort to unspecified codes. The intuitive rules engine learns physician behavior and anticipates what is needed to obtain maximum reimbursement for the patients they work with, whilst depicting the true sickness of the patient population. Vincari’s users have no need for a Grace Period. Period.