Claims Adjudication and Payer Rules under ICD-10

Rayellen Kishbach's picture

Because we process thousands of LCDs updates weekly for our Coding Suite, we often get some insights that we can share. With the implementation of ICD-10, a significant drop off in the number of local coverage determinations (LCDs) and coverage articles published by the Medicare Administrative Contractors (MACs) has occurred. (See table in the white paper link below). While this may be partly due to MAC consolidation, it has left providers with less guidance than before about the proper coding and billing of covered services.

In addition, the switch to more specific ICD-10 diagnosis codes impacts both coverage and the way providers document and bill for services. Higher specificity of coding allows coverage criteria to be more specific. For example, consider the medical necessity for insulin pumps, which are covered for patients with complicated diabetes. Formerly, ICD-9 code 250.03 (Type I “uncontrolled”) was a suitable code to validate necessity, while now it is common for coverage to be limited only to E10.64 (with hypoglycemia) or E10.65 (hyperglycemia), eliminating coverage for a number of other codes that CMS has designated as “generally equivalent” to the predecessor ICD-9 code 250.03.

Current Awareness Tools from Wolters Kluwer and Canary Insights

It is essential to check in on the coding, coverage, payment and regulatory updates that impact your business regularly, and the challenge with that is the reality that coding and coverage rules can change weekly. During a recent inventory of dozens of medical product manufacturer reimbursement guide pages, our editorial department found that over 50% were out of date or contained inaccurate information.

Don’t be caught with outdated reimbursement communications documents, get the tools you need to keep you ahead of change:

  • The Coding Suite provides up-to-date coding, coverage, payment and regulatory updates, and can be customized to send you email alerts specific to your speciality. Track all national and state updates for Medicare and Medicaid in one simple tool.
  • Canary Insights extends this intelligence into the private payer space, with monitoring of hundreds of private payer sites with an on-demand search, as well as customizations based on your therapeutic landscape. Canary even includes a comprehensive payer directory and calendar so that you know when and who to contact.

We can help!

Download the Life Sciences Reimbursement Strategy Trends white paper here: