Medical Reimbursement Specialist


ICD-10 will be in effect on October 1, 2013!

Twelve Steps per CMS:

1. Organize the implementation effort. This includes establishing a point person to oversee the conversion. Choose someone who is familiar with the departments that the code changes will most heavily affect. Include coders, information systems, billing, managed care contracting, and physicians in the development of your implementation plan.

2. Establish a communication plan to keep everyone up to date on the progress. Communicate with stakeholders on a monthly basis until six months prior to implementation, at which point you should communicate biweekly, according to the CMS presentation. Determine which method of communication is most appropriate for each team player. For example, some staff members may not respond to e-mails or memos and may benefit instead from short meetings with verbal updates.

3. Conduct an impact analysis, which includes a budget for system updates, staff member training, and coding resources. Don't forget to include the additional staff member time needed for the conversion.

4. Contact system vendors to ensure that they are ready for implementation well in advance of October 1, 2013. Physician practices should already be talking with vendors about compliance with the new HIPAA 5010 transaction standard. All covered entities must comply with this new standard by January 1, 2012. Ask your vendor when it will be ready to test the systems. One vendor explained that it cannot test its systems until the Medicare administrative contractors (MAC) are fully compliant. CMS recommended that providers forward information from their MACs to their vendor because CMS and MACs correspond with providers, not vendors.

5. Estimate the budget for transitioning to the 5010 transaction standard, taking into account costs for hardware, software, licensing, and training. The budget will vary depending on the practice size and the tools that your practice currently uses for coding and billing.

6. Plan the implementation beginning in early 2010. Review superbills at this time by crosswalking current codes to equivalent ICD-10-CM codes.

7. Develop a training plan. Focus on who needs training and how many hours will be required. Find out what resources are available and make a schedule.

8. Analyze business processes that are currently tied to ICD-9-CM. This could include medical policies and contracts with health plans.

9. Begin the education and training at least six months prior to the October 1, 2013, implementation deadline (for small practices). Large practices may need more time.

10. Address policy change development. Do you have contracts with Medicare Advantage plans or other health plans that base payments on patient severity of illness? For example, Medicare uses beneficiaries' characteristics (e.g., age and prior health conditions) in its CMS–hierarchical condition category risk adjustment model. The model uses ICD-9-CM diagnoses to predict expected resource utilization for each beneficiary. Medicare Advantage plans benefit from higher capitated payments when their covered lives are deemed high risk. There may be some new opportunities to appropriately improve payment with ICD-10 coding, which may better reflect your group's patient severity of illness.

11. Test the system (i.e., the deployment of the codes). Seek assistance from your vendor to do this. Make sure there is adequate time to perform the testing and allow for necessary internal customizations. The vendor should ensure that updates will be maintained during transition.

12. Track implementation compliance. Monitor all activities to identify potential problems after the implementation is complete. If payments are reduced or slower than usual, investigate whether the problems are related to a certain payer or are general in nature. A general slowdown could indicate that the problem is related to the practice's processes. Ask the following questions to track implementation compliance:
•Are superbills used consistently and appropriately? •Are coders able to choose the correct diagnoses in a timely manner? •Are there delays in getting the claims final billed? •Do explanations of benefits indicate denials that were not present before the conversion to ICD-10-CM? Track what payers deny to determine whether there is a pattern to the denials. •Are other practices that use the same vendors or clearinghouses having the same problems?

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Reimbursement Specialist
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