Ask the Expert: How ICD-10 Affects ASC Billing

Q: How do ICD-10 codes affect the ambulatory surgery center (ASC) billing process?

Angela Mattioda, Senior Vice President, RCM Solutions and Client Experience, Surgical Notes: ICD-10 codes are used by ASC physicians when diagnosing their patients. The codes selected can greatly affect an ASCs ability to successfully bill and get paid for the procedures intended to treat the diagnosis.

When ASC coders are coding, it's vital to identify upfront whether the local coverage determination (LCD) has been met. When Surgical Notes coders perform the coding, they use coding software that tells them if the included ICD-10 code meets LCD requirements. Our coders will note whether LCD has or has not been met or whether there is no LCD listed, which means there are no requirements tied to that procedure code.

It's important to also utilize coding software for commercial payers even though LCD requirements are specific to Medicare. Commercial payers have their own clinical policies, and many follow Medicare guidelines.

If coders fail to perform this task, the responsibility falls to the billing team because you should address any issues with LCD not being met on the front end. Failing to do so means the procedure is not going to be paid. It's a waste of time and resources to move forward with an unresolved ICD-10/LCD issue as that is going to result in a denial.

ASCs should work to address such an issue by pulling the patient's history and physical (H&P) and conducting a code review. The H&P will often include additional information that can help a coder determine whether an addendum to the operative note would suffice. This addendum might speak to missing verbiage. There could be pieces of information left out. The way descriptions are worded could result in an ICD-10 code that does not meet the medical necessity requirements.

When you have an ICD-10 code that does not meet the LCD requirements, it's often because the ICD-10 code is unspecified. Like an unlisted CPT code, an unspecified ICD-10 code is often due to a lack of detail.

Unfortunately, problems with ICD-10 are not uncommon. The reason is largely that the change from ICD-9 to ICD-10 in October 2015 saw us move from 13,000 diagnosis codes for ICD-9 to close to 70,000 diagnosis codes for ICD-10. This increase in codes is because ICD-10 codes are much more detailed. It can be difficult for providers to break the habit of dictating a particular way that worked for ICD-9 but no longer works for ICD-10. It's contingent upon ASC coders and billers to flag when ICD-10 shortcomings are causing an LCD issue that, if left unresolved, will lead to a denial.

This is an area where provider education and provider cooperation is critical. When providers struggle to or are unwilling to adapt to meet the more detailed needs of ICD-10, it can result in a loss of revenue for the ASC.