Thursday, October 25, 2012

ICD-10 Claim Submission & Processing Scenarios – Pay Attention to the Boundaries

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?


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?

Hopefully the above scenarios will spur some thought about preparing for the ICD-10 compliance date.  You can learn more about ICD-10 by following me - @ShimCode - on Twitter

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