In addition to raising the bar for healthcare professionals with respect to filing health insurance claims, the impending ICD-10 transition will also up the ante of health literacy for patients.
That's because patients will more often be required to provide more accurate and in some instances more detailed information related to their reasons for seeking medical care.
The reason is doctors and other health care providers will have to bill using more numerous and more specific diagnosis codes after the change.
Services for which health literacy will be most important are initial ones with new healthcare providers and those for new medical problems.
New providers often do not have complete records and all of the diagnoses related to a given visit.
Even if they do, some of the diagnoses under the current ICD-9 coding system will be different under the ICD-10 system.
New diagnoses most affected will be those made based on information patients provide rather than those based on the physical examination and tests.
Health insurance companies match service codes with diagnosis codes in deciding whether or not to pay claims providers submit to them.
Service codes (CPT codes) indicate the service provided.
ICD (International Classification of Diseases) codes explain the reason(s) for the service.
If there is a mismatch of the codes an insurer will not pay part of or the entire claim.
More simply put, if the reason(s) for a service does not justify the actual service insurance companies consider the service or a portion of it to have been unnecessary.
Claims denials based on service/ICD-10 code mismatches could be the result of the use of incomplete codes or codes that are not specific enough.
Incomplete codes are those that require one or more additional digits or an additional code.
Codes that are not specific enough are those listed in the ICD-10-CM coding manual as unspecified codes.
Healthcare providers can avoid payment denials by always using specific codes that match the service provided.
But if their medical records don't contain the documentation to justify the use of those codes that practice carries a risk of being audited and possibly charged with fraud.
Their use of unspecified codes because of insufficient medical documentation to justify the use of more specific codes is not fraudulent.
But excessive use of those codes can result in an insurance company audit.
Depending on the outcome of the audit, the insurance company might elect to exclude a provider from their program or request monetary paybacks.
Claims denials don't result in adverse consequences for just providers.
If the denial is due to a coding mismatch resulting from insufficient documentation in the medical record and if that deficiency was due to the patient's inability or unwillingness to provide the necessary information, the patient is responsible for the cost of the service(s).
This is especially true if the healthcare provider clearly records the unsuccessful attempt to obtain that information.
The need for stronger medical documentation is what will significantly raise the stakes of health literacy following the ICD-10 transition.
The reason is patients and caregivers will need to be able to obtain, understand and utilize basic health information in order to provide relevant facts related to request for medical care.
Hence, healthcare providers can more accurately document and justify their use of the codes.
That's because patients will more often be required to provide more accurate and in some instances more detailed information related to their reasons for seeking medical care.
The reason is doctors and other health care providers will have to bill using more numerous and more specific diagnosis codes after the change.
Services for which health literacy will be most important are initial ones with new healthcare providers and those for new medical problems.
New providers often do not have complete records and all of the diagnoses related to a given visit.
Even if they do, some of the diagnoses under the current ICD-9 coding system will be different under the ICD-10 system.
New diagnoses most affected will be those made based on information patients provide rather than those based on the physical examination and tests.
Health insurance companies match service codes with diagnosis codes in deciding whether or not to pay claims providers submit to them.
Service codes (CPT codes) indicate the service provided.
ICD (International Classification of Diseases) codes explain the reason(s) for the service.
If there is a mismatch of the codes an insurer will not pay part of or the entire claim.
More simply put, if the reason(s) for a service does not justify the actual service insurance companies consider the service or a portion of it to have been unnecessary.
Claims denials based on service/ICD-10 code mismatches could be the result of the use of incomplete codes or codes that are not specific enough.
Incomplete codes are those that require one or more additional digits or an additional code.
Codes that are not specific enough are those listed in the ICD-10-CM coding manual as unspecified codes.
Healthcare providers can avoid payment denials by always using specific codes that match the service provided.
But if their medical records don't contain the documentation to justify the use of those codes that practice carries a risk of being audited and possibly charged with fraud.
Their use of unspecified codes because of insufficient medical documentation to justify the use of more specific codes is not fraudulent.
But excessive use of those codes can result in an insurance company audit.
Depending on the outcome of the audit, the insurance company might elect to exclude a provider from their program or request monetary paybacks.
Claims denials don't result in adverse consequences for just providers.
If the denial is due to a coding mismatch resulting from insufficient documentation in the medical record and if that deficiency was due to the patient's inability or unwillingness to provide the necessary information, the patient is responsible for the cost of the service(s).
This is especially true if the healthcare provider clearly records the unsuccessful attempt to obtain that information.
The need for stronger medical documentation is what will significantly raise the stakes of health literacy following the ICD-10 transition.
The reason is patients and caregivers will need to be able to obtain, understand and utilize basic health information in order to provide relevant facts related to request for medical care.
Hence, healthcare providers can more accurately document and justify their use of the codes.