Who assigns the diagnosis codes that go on your HIPAA-CMS claim forms for purposes of reimbursement? Only ICD codes are allowed on claim forms, so someone, somewhere within your organization has been putting the ICD-codes on the claims.
There are several possibilities:
- Your billing person or office,
- A Certified Professional Coder (CPC),
- Your clinician, or
- Someone else.
The next questions are: Who is allowed to put the ICD codes on the claim form? What are the protocols or state laws for who can assign diagnoses in your state? What happens if the person assigning the code does not realize they are assigning an ICD code, but instead believes they are assigning a DSM code? Is it allowed for the billing office personnel, who are frequently not CPCs in our industry, to assign diagnoses, utilize a crosswalk they found on the internet, or “assume” the code will automatically match “because it has always matched in the past?”
The last question is: how will you manage this when we switch to both ICD-10 and DSM-5? The "typical" practice is common in the field across the country: clinicians at the point-of-service/care delivery are assigning DSM-4-TR or DSM-5 codes, submitting them to the billing office, and move on to the next task. In turn, the billing office submits an ICD-9 code on the claim form, a common workflow in provider organizations.
While “seamless” in the past, this will all change with ICD-10. When the switch is flipped on October 1, 2015, there will be major problems for claims submissions, revenue cycles, and denied claims. Most importantly: can your billers assign a different diagnosis code than what the clinician assigned at the point of care just because the code the clinicians assigned (“all we need is a DSM code”) does not exist in the ICD-10?
Clinicians have been told that all they need to know are DSM-5 codes. This is not an accurate statement and the responsibility of accurately diagnosing the consumer falls squarely on the clinicians shoulders. It is a misleading statement, giving a false sense of security for using a publication that contains non-HIPAA endorsed code (not to mention typos of all sorts). If you employ CPCs, then you are fine, but most organizations in our industry do not. If you are not using CPCs, then your compliance department, and exposure to risk, is significant.
Some helpful tips to consider as we move towards ICD-10 Implementation: