ICD-10 impacts to providers – Scheduling : Preauthorizations and Certifications

Does your organization have Standard Operating Procedures (SOPs) that use ICD-9 CM diagnosis or ICD-9 procedure code information?  If so, those procedures and systems need to be evaluated as part of the ICD-10 Impact Assessment.

In medium to large, multi-site health systems, a centralized scheduling team responsible for scheduling the majority of the diagnostic services and the pre-testing for OR cases often performs this function.  Phone calls and faxes with patients and physician offices are coordinated.  AT the point of scheduling the scheduling team collect the basic patient information and test specific information as determined by the department.   Scheduling software usually has a menu of services used to schedule and often the diagnosis description at the time of scheduling is collected.  Once the test is scheduled the account is passed to pre-registration.

If in this process your organization uses ICD-9 diagnosis codes as a required component of the patient intake, those systems and processes must be remediated.   Recently we spoke to an outpatient facility that does just that, assigning the ICD-9 CM diagnosis code BEFORE the physician encounter.  In fact for this particular provider, the physician was not able to assign a diagnosis code in the EHR at all!  This would not only be an ICD-10 unfriendly approach in terms of process and electronic health record clinical documentation, but one that could open the organization up to RAC audits and less than desirable documentation of medical necessity for determining the viability of a health care claim.   Utilization management departments of health plans use such data in medical records requests to determine whether a claim should be paid and what portion, if any should be paid.   Therefore this component of the ICD-10 assessment is important as it has revenue cycle impacts.   A failure to remediate this issue would also compromise ICD-10 data quality going forward.

Often this type of information is buried in your organization and it is important to find all such cases.  Large health systems may have 200 to 300 discrete systems, both off-the-shelf and custom built.  It is not unusual for at least 1 in 5 of these systems to be impacted by ICD-10

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.