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Three Steps to Selecting the Right ICD-10 Codes


ICD-10 code selectionThe October 1, 2014 deadline for implementing ICD-10 codes is sneaking up behind you. Is your practice ready to make the transition from ICD-9 to ICD-10?

If not, your practice faces some rough times ahead. The 2014 ICD-10 contains nearly 70,000 codes, providing ample room for error when selecting codes. Almost none of the code numbers remained the same from ICD-9 to ICD-10, and it is not as easy as translating the old ICD-9 codes into new codes.

A poor transition from ICD-9 to ICD-10 has real consequences for any practice, whether it is a large hospital or single practitioner practice. Selecting the wrong ICD-10 codes will result in disruption of reimbursements, low reimbursements, and claim denials. Ill-prepared coders will likely grow frustrated with returned claims, denied claims, and requests for more information.

Fortunately, you can select the right ICD-10 codes in just three easy steps.

Step 1: Use the ICD-10 alphabetical index

Locate the main term in the alphabetical index. Review the list of sub-terms and select the most appropriate sub-term specific to the case. Read the instructional notes about how to add terms like “see,” “see also,” “with,” "without,” “due to,” and “code also.”

The “see” and “see also” instructions in the alphabetical index mean you should reference another term to find the correct code. The “code also” note describes a case where you will need to enter two codes to describe the situation fully.

Step 2: Verify the code with the tabular list

Use the tabular list to verify the code. The tabular list groups the ICD-10 codes according to chapter, categories, and subcategories. Be sure to review the notes appearing at the top of the tabular list, as that information can help you select the correct code.

The tabular list allows you to provide more information about the visit. Use the tabular index to describe the severity of the patient’s condition and any complications associated with the case.

The tabular list helps you reduce your selections to only the appropriate codes. Use the tabular list to describe “Excludes 1” and “Excludes 2” rules that identify codes you should never use together and at the same time, respectively. Excludes 1 would prohibit you from entering J05.0 with J04.0, for example, because both describe acute laryngitis.

Furthermore, the tabular index contains information that determines the length of the code, which can be anywhere from three to seven characters long.

Step 3: Review coding guidelines

Read over those coding guidelines at the top of the alphabetical listing. It includes specific information for some of the more complex codes, such as sepsis and HIV. Miss this section and you might miss vital sequencing guidelines. The sequencing order for a patient with anemia resulting from malignancy, for example, is completely different from a case where chemotherapy, radiation or immunotherapy caused anemia.

You can reduce confusion, frustration and loss of reimbursements by preparing your practice for the ICD-10 transition now. Encourage all staff members to learn how to implement the new ICD-10 codes into your practice. Teach these three easy steps to every worker who records information about patient care and ease the tension in your office when October rolls around.

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ICD-10 Planning and Assessment


ICD-10 implementationIf your practice or organization hasn’t already begun the processes of assessing, planning and implementing training and other matters related to transitioning to the ICD-10 coding October 1, 2014 deadline, there is still time to become trained, systems-ready and become compliant before then. If you’re not sure where to begin or what considerations and tasks should be on your readiness checklist, M-Scribe and its team of experienced professionals can help make the transition process easier and faster for you and your staff.

Perhaps the most critical part of a practice’s successful transition to the new ICD-10 coding system is the Planning and Assessment stage. Proper planning lays the groundwork for your health care billing team to obtain the necessary upgraded software, equipment, and training as well as to develop staff proficiency with the new coding system well ahead of the October deadline. Waiting until the last minute can result in overlooking necessary tasks and processes, leading to frustration, deficiencies in staff ICD-10 readiness training, unexpected software and other systems upgrades causing billing, posting and other delays, as well as other coding and billing headaches.

M-Scribe’s team can assist you and your staff with the following tasks to ease the transition to ICD-10:

  • Develop a list of tasks that need to be completed prior to implementing the ICD-10 coding in your practice or organization, as well as develop a realistic timetable for completion. These will include identifying tasks, those responsible for executing each task, resources and other dependencies specific to your practice or organization, its existing policies, processes and systems, as well as where the current ICD-9 fits in with the organization, and the expected effects of ICD-10 changes to the practice, including electronic health records.
  • Identify and plan a realistic and comprehensive budget that includes upgrades to software as well as training expenses, coding guides and Superbills.
  • Work with you to designate transition responsibility to either one person among your staff or to a committee, depending upon your organization’s size and budget.
  • Review the facts and background information about ICD-10 and its benefits with both management and billing staff. The new coding’s benefits include expanding the flexibility of coding by increasing the length to seven characters, thus permitting coding specific complications, severity, conditions and other factors affecting accuracy and detail. More detailed reporting as well as analytics outcomes and utilization should result in improved claims reporting and processing on both the practice’s end as well as with the carriers. When your staff understands the reasons behind the new coding, learning the new ICD-10 system will seem less burdensome.
  • Identify necessary changes to systems, as well as costs and testing to successfully transition. You will also need to ask your software and/or systems vendors about the time frame required for testing, including starting and ending dates.
  • Review transition plans and contracts with affiliated physicians and hospitals, trading partners and other vendor agreements, including billing services, clearinghouses, and software or systems vendors for their ICD-10 readiness.

Once the initial planning and needs assessment is in place, M-Scribe’s team can assist you with the implementation and adoption of ICD-10. Your practice should find that with the adoption of ICD-10, with its more sophisticated and detailed coding, it will be easier to establish more efficient payment services as well as weed out fraud and abuse, improve medical decisions on a clinical level, measure the quality of patient care and keep track of issues in public health.

M-Scribe Technologies, LLC has been a leader in the health care billing and documentation services industry since its founding in 1999, serving practices of all sizes and specialties. Contact us today at 888-727-234 or visit us online for an in-depth consultation and evaluation of your practice’s unique needs to ensure that your organization is ICD-ready and compliant before the October 2014 deadline.

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Don't Allow New Documentation Rules Translate to Lower Quality Patient Care


New Documentation RulesAccurate patient record documentation requirements hopes to "foster quality and continuity of care." Additionally, medical record standards target improved lines of communication between providers, patients and providers, along with provider to payer communications.

While payers establish their own expectations, all expect accurate evidence-based documentation, preferably electronic. Payers, including Medicare and Medicaid, develop their own checklists, but most requirements include the following items.

Typical Payer Documentation Expectations

Patient medical records should always include the following data.

  • Clear identification of patients on each document component.
  • If kept in "paper" files, legible entries in high contrast ink, preferably black or dark blue, on all documentation to minimize reader error.
  • All recorded entries should be clearly dated and authenticated by the provider.
  • Use accurate codes, supported by equally thorough documentation.
  • Employ on common (standard) medical abbreviations, eliminating misunderstandings in translation or entry.
  • Include every patient "encounter," including phone, fax and electronic messages.
  • Clear recording of problems, medical conditions, medications, allergies, physical exams, immunizations, lab and diagnostic test results, diagnosis factors and treatment plans.

Payers will complete periodic document reviews, to evaluate the accuracy, clarity and thoroughness of submitted provider documentation. Claim delays and/or denials may result if documentation does not achieve, at least minimum payer standards.

Providers and their billing staff are cautioned to pay particular attention to the new coding system, as simple "typos" will typically cause reimbursement delays, at a minimum. Correcting an unjust claim denial because of deficient documentation is more difficult and time consuming than submitting it accurately initially.

Combine Quality Care with Cost Control

Healthcare reform demands delivering quality care, while employing new mandates, including more detailed documentation, seamlessly for maximum patient and provider benefit. Optimizing clinical documentation is a key to maintaining revenues. But, will it affect quality patient care?

The new requirements for "meaningful use" justification, pay-for-performance plans and ICD-10 codes are daunting changes in documentation, but should not result in lower quality care. Providers should find ways to lower and control costs, while maintaining their level of patient care.

Capturing and reporting accurate information has never been more critical to generating revenue, claims submission and patient communications. Medical providers should evaluate the cost management advantages of outsourcing some functions to leading billing, coding and documentation firms, such as M-Scribe Technologies, to remove much of the pressure to improve patient care while also tightly controlling expenses.

Practice staff under additional pressure face major performance challenges. Is it really wise to subject possibly maxed-out personnel to increased pressure of additional, unfamiliar documentation requirements? Probably not.

Similarly, is there any wisdom in medical providers in putting this extra pressure on themselves to lower and control costs, while improving patient care? The answer is easy: No. The bottom line remains the delivery of quality care. The rest of a successful bottom line financial equation will follow.

Increased documentation should not negatively impact quality patient care. Although there is a natural learning curve with any new policies, procedures and requirements, the negative implications can--and must--be minimized. How this goal is reached is typically up to the provider and/or the practice.

However, medical providers will rue the consequences of allowing new documentation necessities to interfere with quality patient care delivery. Even if the immediate concerns are maintaining strong revenue and lowering expenses, delivering quality care will become much more vital in the longer term.

Practitioners delivering consistent, quality care will eventually eliminate the potential negatives in complying with documentation and communication requirements. Just as new coding and digitizing patient medical records is challenging, the future should eliminate these fears, as more providers and practices become comfortable with these realities.

The future health of your patients and practice depends on marrying quality care with cost control and creating clear, accurate documentation. Is this a challenge? Yes. Is it possible? Also, yes.

ICD\u002D10 and Documentation
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Will Pay-for-Performance Techniques Help Control Expenses and Maintain Strong Revenue?


Pay-for-PerformanceThe medical provider community is not enamored with the "pay-for-performance" (P4P) initiatives now dominating the payer landscape. Incentive-laden payment schedules dramatically contrast with classic fee-for-service (FFS) payment systems.

Depending on the components used, P4P systems can take various forms. However, regardless of the elements considered by payers, the medical community continues to favor FFS, as it compensates for the quality of services rendered without evaluation of performance.

Medical professionals have multiple concerns with performance-based measurement systems. Often, the primary questions and issues involve two concerns.

  • Will P4P systems help or hurt controlling expenses?
  • Can I maintain current revenue or increase income with P4P payer techniques, in light of healthcare reform, new ICD-10 coding and documentation requirement increases?

Understanding Pay-for-Performance Logistics

The first requirement is to understand the foundation and goal of P4P systems. The goals of P4P systems is rather straightforward: Define incentive rewards for physicians and other medical providers for improving health care for patients.

The measurement details and standards payers use is much more complex and argumentative. This is the primary area of contention, with no consensus among the medical or payer community as yet. The depth and breadth of performance measurement benchmarks, often stated as the "clinical outcomes" of diagnosis and treatment choices, has generated heavy discussion and, sometimes, strong disagreement.

According to leading research institute, RTI International, many payers use the following factors as the foundation for P4P logistics when designing systems.

  • Clinical outcomes.
  • Clinical process quality.
  • Patient safety.
  • Access to and deliverance of quality care.
  • Patient satisfaction levels.
  • Cost of care efficiency.
  • Adoption of and adherence to an "evidence-based" practice.
  • Proper use of information technology.

This list is not all-inclusive, as some payers use performance standards with more measurement factors. Unfortunately, to date there is little agreement on P4P design details or the projected results.

Expense Control

P4P and evidence-based medical practice almost mandate that physicians cut or, at least, tightly control costs. Since payers often use cost-efficiency as a critical P4P component, practitioners' data may be compared to other providers' efficiency as a measurement tool.

While this incentive standard works "on paper," there is medical community concern how it will impact P4P results in the real world. Depending on the payer benchmarks used, the cost-control requirement will have an impact on most practice ratings.

Even if a P4P system is committed to fair and equitable evaluation, will practice personnel understand the necessary expense limitations placed on physicians and practice managers? Maybe, the best way to exercise expense control is to outsource many functions to a top practice management firm, such as M-Scribe Technologies, to handle billing, coding, documentation, etc. This solution gives practices cost-certain control with managing patient- and service delivery-related expenses.

Revenue Maintenance and/or Improvement

The healthcare reforms, new ICD-10 codes and increased documentation requirements are strong challenges to maintaining or improving practice revenue levels. The medical community's concerns appear to be well-founded.

P4P, although touted as an incentive program, can deliver hidden (or not-so-hidden) penalties to medical providers by reducing, not increasing, revenue. Until a consensus is reached regarding standards and measurement techniques, medical providers will continue to debate the merits and detriments of P4P.

The "learning curve" associated with massive reforms, coding and unfamiliar documentation requirements temporarily could generate revenue challenges that practitioners cannot overcome. Should this occur, providers dedicate all efforts to master these necessities as soon as possible to restore former revenue levels.

Once again, it appears wise for providers and practice managers to consider outsourcing functions to top, proven, professional third-party firms to safeguard revenue. Their staffs have been thoroughly trained in billing, coding and documentation changes needing mastery to keep revenue flowing strongly.

Avoiding claim delays and denials with accurate billing, coding and documentation submission is vital with or without P4P systems. Until the longer term results take place, medical providers probably will continue asking if pay-for-performance techniques will help or hurt cost control and revenue levels? Can you blame them?

ICD\u002D10 and Documentation
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Making Best use of ICD-10 Index and Tabular Lists


ICD 10 Dermatology ClinicsHow can dermatology practices use ICD-10 Index and Tabular Lists to effectively meet conversion challenges?

The ICD-10 Index & Tabular List

The National Center for Health Statistics is the official repository of ICD-10-CM documents. The official source documents are: The ICD-10-CM INDEX TO DISEASES and INJURIES and The ICD-10-CM TABULAR LIST of DISEASES and INJURIES. The disease and injury index shares the same characteristics as most book and document indices. It provides a quick way of referencing code categories. The best way to use the index is to let it guide us as to where to look within the ICD-10-CM tabular list.

The tabular list is comprised of a comprehensive ICD-10 codes listing. Individual chapter breakdowns are typically based on body systems. An example in Dermatology is chapter 12. This is where Diseases of the skin and subcutaneous tissue can be found. This chapter is assigned the letter L, so all codes in this chapter will start with L.

At the beginning of chapter 12 there is an excludes 2 clause including such things as parasitic diseases (A00-B99), metabolic diseases (E00-E90) and viral warts (B07). Notes can provide clarification. Such notes include Includes Notes, Excludes Notes such as Excludes 1 and Excludes 2 and See Notes. The top level heading covering codes L00 to L99 is followed by an excludes 2 note. This Excludes 2 Note clarifies that the listed diagnoses aren’t part of the represented code, and can be made at the same time.

Types of Notes

Excludes1 notes indicate that coding the listed diagnoses together is invalid. Given a patient diagnosis of acquired epidermolysis bullosa (L12.3), it’s invalid for a congenital EB diagnosis to be given at the same time, as congenital and acquired are mutually exclusive. The Excludes1 note guides practitioners to select just one code.

Excludes2 notes indicate that differing codes can co-occur. Diagnoses that aren’t part of the code can be coded at the same time. Acne is in category L70. An Excludes2 note informs the practitioner that acne keloid is not found among L70 diagnoses so it can be listed as well.

See notes indicate places to look for related codes. Poison Ivy is a type of dermatitis. When checking in the Index, you might start at Dermatitis and then under Contact and Allergenic.

See Also notes provide alternative index locations when looking for a code. Looking in the index under papilloma, the index directs you to look under NeoplasmsBenign, or “by site”.

Use Additional Code indicates that an additional code is required. Given a patient with impetigo, (L01), the recommendation to use an additional code identifying the infectious agent (B95-B97) is given.

Code First note urges the practitioner to use an additional code as the first code on the Superbill. Many Code First notes describe variations of a larger disease. In the L14 category of Bullous disorders in diseases classified elsewhere, a patient has a “bullous” subtype of Systemic Lupus Erythematosus(SLE), in which the lupus is causing blisters. The diagnosis associated with SLE (M32.8) is inadequate. Instead, the Code First note suggests using the M32.8 code for SLE, and then adding the L14 code to indicate “bullous changes”.

It’s clear that dermatology practices will make extensive use of ICD-10 Index and Tabular Lists to identify the correct ICD-10 codes for record keeping and claims processing after October 2014. These documents are a primary resource for locating and applying the correct code. Their use will help ensure that comprehensive and accurate medical information is available to help practitioners, patients and researchers.

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The Role of ICD-10 in Improving Business Goals


ICD 10 business GoalsOpposition to ICD-10 is strong from the AMA and other forces, due in part to the excruciating level of detail the new coding system demands. But that same deep level of detail may eventually be realized as a major benefit for advancing the goals of healthcare practices as well as the industry as a whole. Healthcare data mining and data analysis have already been benefiting the healthcare arena, and the deeper level of details ICD-10 promises to produce may increase the benefits even further.

ICD-10 Enhances Data Analysis

A quick review of some of the changes between ICD-9 and ICD-10 pointed out by the Centers for Medicare and Medicaid Services (CMS) make the increased precision immediately evident. The new system increases the number of codes, the numbers of characters in each code and adds more specificity to the coding process. ICD-10 allows for the description of etiology and causation, manifestations and complications, comorbidities, level of functional impairment, detailed anatomical location and other details not available with ICD-9.

CMS notes the switch can benefit healthcare providers by:

  • Accommodating more recently developed diagnoses and procedures
  • Allowing for innovations in treatment
  • Enhancing performance-based payment systems
  • Providing billing that is more accurate, streamlined and efficient

While such benefits can contribute to advancing the goals of a practice, ICD-10 may bring even greater benefits in the way of healthcare data analysis. An article published in the International Journal of Engineering Research and Applications points out the numerous benefits healthcare data mining can bring to the industry, and those benefits can be multiplied with the implementation of ICD-10.

Evaluation of Treatment

Healthcare data analysis can be a useful tool for determining the effectiveness of specific treatments. By comparing and contrasting the symptoms, causes and courses of treatment, healthcare data mining may play a role in discerning the most successful medication doses, therapies or other treatment modalities.

Management of Healthcare

Healthcare data mining software or applications could help identify and keep track of high-risk patients and chronic diseases. Analytical tools could help healthcare providers develop effective interventions, resulting in a reduced need for hospitalization and fewer overall claims.

Closely tracking specific conditions or ailments could also alert providers of a potential outbreak of infections, whether within the hospital parameters or throughout the community or nation as a whole. In addition to serving as an early warning sign of bio-terrorism or an epidemic, results from data analysis could assist with predicting the risk and survival analysis for patients with AIDS or others suffering from certain injuries or conditions.

Management of Customer Relations

Customer relations may be improved through healthcare data analysis, particularly for predicting specific usage patterns, preferences and needs of individuals. Such information could be applied to customer relations in various arenas, including physician offices, billing departments, call centers, inpatient and ambulatory care settings.

Additional Uses of Data Mining

The adoption of electronic health records has already allowed medical and healthcare facilities to amass large quantities of pertinent patient data. Such data can be analyzed to determine specific needs of patients based on their medical histories and current status.

Examples include alerting healthcare professionals about patients that may benefit from preventive measures, flu shots or a disease management program. Focusing on predictive analytics, providers may be able to assess the likelihood of a particular patient to adhere to his or her treatment program based on past behaviors and other pertinent factors.

Although ICD-10 continues to battle its opposition in the present, it may serve as a valuable implementation going forward. Not only could it help individual practices of facilities advance their business goals, but it could enhance the entire industry.

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Tips for Making a Seamless Transition to ICD-10


ICD 10 TransitionWith the required implementation of ICD-10 on the horizon, many hospitals, medical facilities and private practices are struggling to make the necessary changes to meet the new standards. While the changes from ICD-9 to ICD-10 may seem varied and complex, the transition need not be a worrisome struggle. It can instead be a rather seamless transition with a few practice management suggestions to help meet the Oct. 1 implementation deadline.

Awareness of Coding Changes

Being aware of two major coding changes can be the first step in effectively implementing them. The federal Medicaid website reports they are:

  • Expansion of code set: Code sets in ICD-10 consist of seven positions, with each position supporting alphanumeric characters. ICD-9 had only five positions, with only the first position open to alphanumeric characters.
  • Increase in number of codes: The number of ICD-10 codes is 68,000 in ICD-10, a substantial increase over the 13,000 codes in ICD-9.

Early Preparation

Although ICD-10 cannot be put into active practice until its official Oct. 1 implementation date, starting the transition as early as possible is crucial step for an effective transition. It gives organizations the opportunity to troubleshoot any issues while ensuring they are not placed on a long vendor waiting list. Vendors specializing in practice management software and electronic health records are likely to be in high demand, which makes early preparation an essential strategy.

Learning the Most Common Codes

Attempting to learn the entire slate of new codes may be impossible as well as unnecessary. Many healthcare professionals may have a handful of codes they consistently use as part of their practice. Making a list of the most common 20 to 25 codes from ICD-9 and then learning the ICD-10 equivalent can be incredibly helpful, especially in the early phases of the transition. Specific hospital or medical facility departments can use the same strategy, focusing on the most common codes needed for effective practice management.

Identifying Gaps in Descriptors

The new coding system demands greater detail in the way of descriptors, and failing to use them could result in the denial of claims. One way to spot check the attention to detail that will be required is to review existing charts and find any gaps that may occur between the new and old coding systems.

Organizations may examine the existing ICD-9 codes used in the charts then match them up with the equivalent ICD-10 codes, taking note of the key words present in the code descriptions. They can analyze the differences by checking how many claims using ICD-9 would be rejected under ICD-10. This can be a vital learning experience for physicians and staff, illustrating the importance of paying acute attention to the additional detail required.

Ascertaining Vendor and Payer Readiness

Even if a hospital, medical facility or private practice has properly prepared itself for the transition, nothing is likely to go smoothly if the facility’s vendors and payers are not equally as prepared. Organizations would do well to inquire about their vendors and payers readiness to embrace the new system. Key inquiries may include:

  • If electronic health record vendors will have revised templates ready
  • The type of testing vendors are undergoing to ensure an efficient transition

One more key fact that may help with transition from ICD-9 to ICD-10 is to remember the overall goal. Regardless of the extra work the ICD-10 transition may be causing in the short-term, the changes were made to ultimately make the billing process more accurate, detailed and reflective of the changes made in the world of medicine over the past 25 years.

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Preparing for ICD-10 testing


ICD 10 TestingPrioritizing ICD-10 testing, with the most critical scenarios taking place first, is advisable as a preferred strategy. Areas of focus include business, clinical and operational functionality. Individual health care payers must each schedule their own end to end testing. Test plans, real medical data and collaboration with partners are all part of the process.

Creating accurate test data for ICD-10 is challenging as this type of data has never before been implemented in full-scale production environment in the U.S. For some indication as to what may happen, we should look north: ICD-10 has been in full production in Canada since 2002. According to AHIMA, Canadian productivity decreased from 4.62 charts per hour just before ICD-10 implementation to 2.5 charts per hour 3 months later, but rebounded to 3.75 charts by 2003 (1 year later). Conversion participants note that both analytical tools and human decision making tools are necessary for success.

ICD-10 implementation will ultimately provide precise diagnoses and treatments, more accurate payments and better tracking of treatment results. Coding mismatches are likely to affect operations for some time: the US Dept of Health and Human Services anticipates an increase in claim errors of 6% to 10%.

Positive Outcomes of Testing

Operational Stability - Accuracy measures such as those for claims payment are maintained at productive levels with new codes.

Clinical equivalency - ICD-9 and equivalent ICD-10 codes define the same characteristics of patient care, and the outcomes meet medical requirements.

Benefit consistency - ICD-9 or ICD-10 code equivalents result in the identical member coverage, with no increase in premiums or co-pays.

Financial consistency - This is the state where benefit payment by the insurer together with recipient copay result in payment coverage.

Real Test Data

Real patient medical data from your practice will provide a solid base for your testing. Using records that reflect the types of cases you treat and submit for reimbursement is the best way to asses the impact of ICD-10 implementation on your practice. Use of test scenarios that match healthcare payers' mappings rather than your practice data is unwise.

Test each of the transaction that will include ICD-10 codes. Transactions and work processes should include claims submission, eligibility and quality reporting.

The AMA provides a fact sheet to meet October 2014 ICD-10 readiness.

Testing Readiness for ICD-10 Overview

Software upgrades are likely to be necessary for your current systems in order for you to be able to send and receive the ICD-10 codes required for reporting and transactions. You must test the systems that send and receive diagnosis codes. Your practice management system is an example. Make certain that the ICD-10 codes are sent from your system, received by the target system, and processed appropriately. HIPAA providers, payers, and clearinghouses are responsible for their own ICD-10 compliance.

The three necessary testing areas to cover are:

  • Sending ICD-10 transactions and reports directly or through a clearinghouse
  • Receiving ICD-10 transactions and reports and processing them in your systems
  • Ensuring payments and cash flow will continue after October 1, 2014

Internal testing is conducted inside a practice. Completing internal testing will allow you to identify and ultimately resolve any internal systems issues related to ICD-10 codes. Testing manual and workflow processes is also important. If your practice works with a billing service, coordinate with them on necessary data collection.

External Testing involves sending and receiving ICD-10 related transactions to your business associates and partners. If the test transactions you’re sending with ICD-10 codes include real patient protected health information (PHI), take care to ensure data privacy. This testing will allow you to identify ICD-10 code issues arising in sending or receiving data. Successful completion of “end-to-end” testing with your partners means that you’re ready to process live transactions.

Overall testing can take 8 to 12 months. Compliance is required for payment as of October 1, 2014.

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Medical Claims Issues Under the ACA


ACA ICD 10 MarchUnder the ACA or Affordable Care Act, Americans have until March 31, 2014 to purchase health insurance during the open enrollment period. This represents a significant extension over the typical open enrollment period, due to the confusion in the new law and the health care website portal. As individuals browse plans and purchase care, those in the medical industry continue to brace for changes. Medical billers who depend on the healthcare industry for their living received a glimpse into how the ACA may affect their positions with the troubled healthcare website rollout in late 2013. While the full impact of the ACA on medical claims is unknown at present, some issues may arise.

More Claims Purported to Hike Premiums

Much has been said about the impact of the Affordable Care Act on medical claims. Critics of the ACA claim that it will raise the cost of medical claims by as much as one-third, because more sick people will now have health insurance. As spending on aged and sick people increases, so will medical claims. To offset this, healthcare premium will increases, critics say.

The truth about whether higher claims levels impact insurance premiums may not be fully known until summer 2014, however, as insurers must first submit their bids. If projections about the numbers of unhealthy people enrolling in healthcare after insurance eligibility verification prove false, there may be little impact on the cost of medical claims.

Delays in Claims Processing as Patients, Insurers Adjust

Whatever the ultimate outcome for medical claims, at present everyone is in a bit of a holding pattern. Medical billers, including those from top third party firms like M-Scribe Technologies, have expressed concern insurance eligibility and precertification problems will arise as more individuals flood the marketplace. In a worst case scenario, this leaves medical billers in flux with a growing backlog of unprocessed claims as insurers wade through paperwork. Billers may be reluctant to process claims without receiving eligibility verification, for fear of retro-termination denials from insurers.

In a best case scenario, billers remain unaffected and can continue to process medical billing. The market for qualified medical billers is projected to grow as more and more individuals who were not insured purchase insurance and receive needed health care.

ICD-10 to Bring New Coding Issues

Meanwhile, medical billing professionals must switch to a new coding system by October of 2014. The new system is much more comprehensive than the present system, but represents a big shift for medical billers. Presently, billers can use the same code when charging for an injury to the left side of the body and one on the right side. Under ICD-10, billers must use one code to refer to the left side injury and a different code to refer to the right side injury. As billers adjust, there are bound to be some mistakes that complicate the medical claims and medical documentation process.

As these issues show, many medical billers are in as much of a state of limbo as insurers and consumers. Everyone has questions about the rollout of the Affordable Care Act and its impact on their jobs. The ACA is supposed to make health care more affordable for everyone, regardless of income. In the short term, however, it seems to be creating more headaches for all involved and presenting medical billers with new challenges. The best in the field will ride these challenges out and continue to thrive under the new healthcare law.


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How the Affordable Care Act Affects Medical Billing and Coding


ACA affects MBCWith all the concern and required training for the new ICD-10 complex coding system, the potential effects of the Affordable Care Act (ACA) on medical billing was overlooked until the last quarter of 2013. It's clear that healthcare reform is not coming without considerable pain, however.

While the supporters of so-called Obamacare were jubilant as the signup and implementation dates approached, most are jubilant no longer. The national and many local healthcare online marketplaces have been an almost total disaster. Healthcare marketplace websites were crashing faster than a Division III Community College football team playing Florida State or Alabama.

Medical billing staff who have focused on ICD-10's over 60,000 treatment and diagnosis codes must now pay close attention to ACA features. According to, the general public is still immersed in a "fog of miscommunication" about the new healthcare rules. Unfortunately, medical billing firm staff does not enjoy this "luxury."

The confusion and despair over the President's decision to renege on his oft-made promise, "If you like your healthcare plan, you can keep it," generated an overwhelming backlash from citizens around the US. This immense pressure forced the White House to take action to allow people to keep their non-compliant health insurance plans, but only for the next 12 months.

Unfortunately, the White House did not reinstate its promise until after most insurers sent policyholders formal cancelation letters, further confusing the already misunderstood process. Physicians, practice managers and other medical providers are as confused as the public about "affordable healthcare."

Among the most common questions from medical providers and billers, the following are important examples. Medical billing staff, whether in-house or team members of top third party firms, such as M-Scribe Technologies, will need answers for physicians, patients and others.

  • How reliable are eligibility verifications? Medical billing staff submitting claims near year's end received numerous denials further hurting practice cash flow and angering many patients. In most cases, practice staff verified coverage at the time of rendering service. While this historically occasionally occurs when premium payments post to the wrong insured's account, medical providers and billers worry that government-administered healthcare may result in even more eligibility errors and denials.
  • Will there be more "precertification" problems or less? Physicians, patients and medical coding staff have endured precertification delays and errors from private insurance companies for years. Will the "governmental connection" increase the length and inefficiency of the precertification process, already a point of negative focus? Replacing one inefficient bureaucracy with another, with more intense and complex one, may not be a workable solution to an existing problem.

These are but two of the numerous issues affecting medical billing and coding staff with ACA implementation. When combined with the plethora of problems afflicting government-sponsored websites for patient signup--before the ACA became law--the medical provider and billing industries cannot be faulted for harboring grave concerns about implementing ACA healthcare reform provisions successfully.

The effects of the past few months have embarrassed, disturbed and angered even the most outspoken proponents of Obamacare. While few, even medical providers, would argue against affordable healthcare, medical billing and coding staff, fearing the possible effects of the ACA, need appropriate answers to physician, patient and/or public questions.

Some medical providers, according to, are referring to Obamacare as a "diversion with false concern for the health and well-being of the American people." While this belief, if true, is sad--potentially dangerous--our medical billing professionals still need to get the information they need to do their jobs.

To date, the potential long-term effects of the Affordable Care Act remain unknown. Healthcare reform, while needed, must involve the efficiency to allow physicians, practice staff, and medical coding and billing professionals to perform their responsibilities effectively. Patients deserve this respect and fair treatment, as do medical providers and their billing entities.

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