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 Arrigo brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health IT, and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations who provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and medical billing, fraud damages, as well as electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, medical malpractice, insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software SA (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls IT audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and is published in Healthcare IT News.

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