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J U N E 2 0 1 5 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
• When will the system upgrade be completed and available?
• Will the updated system be able to maintain and allow for review
of both ICD-9 and ICD-10 code sets by clinical concept?
Additionally, work with clearinghouse and billing vendors to test the
system ahead of time. Test claims submissions in advance with all
payors — no exceptions. Coordinate with your payors, clearinghouses
and billing services on when to send these transmissions to avoid con-
fusion. You also want to ask them whether your system will be able to
support and transmit both ICD-9 and ICD-10 claims since you'll still
need to be able to work with ICD-9-coded claims for older dates of
service, such as rebills, after Oct. 1.
Examine payor contracts and reimbursement policies
Current payor contracts and payment policies may contain lan-
guage that's no longer applicable under ICD-10. For example, condi-
tions deemed medically necessary under ICD-9 may not translate to
medically necessary conditions in ICD-10. To avoid this, review your
payor reporting, documentation and provider requirements, and com-
pare these with applicable ICD-10 draft policies. CMS can provide
your facility with state-specific ICD-10 draft policies for your common
procedures and Medicare population. Review these policies and direc-
tives now to ensure continued medical necessity coverage.
Additionally, check that payor contracts address what happens if the
payor breaches its timely payment requirements. Since ICD-10 may
cause system glitches, ask each payor for its written contingency plan
should there be reimbursement delays. Finally, you also want to ana-
lyze your payor mix, volume and percent of revenue. A disruption in
payment by a single payer can prove disastrous if it's responsible for
25% of your facility's volume and revenue.
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