Most of us who’ve spent any amount of time in the healthcare
business have come to learn – often the hard way – that cutover periods and “boundary
conditions” often present unanticipated operational challenges. The days leading up to and after October 1,
2014 will reveal which providers and payers have anticipated various claims
submission and processing scenarios.
Here’s a list of some claims submission and adjudication/payment
scenarios to consider:
Preadmission Services
Should ICD-9 code(s) or ICD-10 code(s) be used for preadmission
services submitted on an inpatient claim when Statement From (service date) of
the preadmission procedure is prior to Oct 1, 2014 but the Statement Through
(discharge) Date is after Oct 1, 2014?
Services Contracted And Paid As A Unit
Should ICD-9 code(s) or ICD-10 code(s) be used for services
contracted and paid as a unit? – like a month of DME Rental and Global
Pre-Natal Services.
Per-Case or Per-Episode Basis
Should ICD-9 code(s) or ICD-10 code(s) be used for services
contracted and paid on a per-case or per-episode basis? Like Emergency Room Observation and services
paid as an Ambulatory Patient Group (APG).
Interim Bills
If interim bills are processed that span the compliance date, and
the entire episode of care needs to be adjusted, will the portion that preceded
the compliance date need to be restated in ICD-10 codes?
Anesthesia Claims
Which ICD code version should be used for anesthesia procedures
that begin on 9/30/14 but end on 10/1/14?
Preauthorization and Eligibility Inquiries
If a preauthorization or eligibility enquiry is submitted on
9/30/14 for a service to be performed on 10/11/14, which service date should be
used to determine the ICD code version to use?
Readmissions
How should you handle the scenario where one admission is prior to
the 10/1/2014 compliance date followed by a readmission and discharge within 30
days, or within the same benefit period but after the 10/1/2014 implementation
date?