ICD-10 Impact on Physician Profiles

ID-100211229The vote of the U.S. Congress to push back the deadline for ICD-10 implementation to, at least October 1, 2015 may have provided some breathing room, but it doesn't change the outcome.  Adherence to ICD-10 coding will still likely be required at some point.  

However, with all the concerns that had been expressed regarding the upcoming ICD-10 deadline and the ramifications of its implementation, one aspect of the coding process has not received much consideration.  That is the potential negative effects it could have on physicians and other care providers who count on a provider network for support and resources, not to mention a wider client base.  This was addressed in a recent guest article on EMRandHIPAA.com

The Burden of Accuracy

Essentially, this article states that MCOs, health plans and shared-risk organizations hold their physicians, hospitals and other care providers to high standards.  These standards include financial considerations as well as effective patient care.  If procedures and diagnostics are not cost-effective as well as care-effective, subsequent evaluations could find the physician or care facility without a network.  Reputations will rely on the effectiveness of proper coding, and it will be up to the care provider to make sure that the correct codings are applied to a patient's record.  While the physician does not personally assign the codes, he or she is required to provide documentation at a level of specificity that allows for proper coding.  Under the new ICD-10 regulations, the burden of accuracy and efficiency will weigh more heavily than ever before.

The result of inadequate or improper coding will be a red flag to network organizations that profile physicians.  For example, if a patient is diagnosed having a particular illness and receives the standard care for that, but upon further examination is found to have an accelerated level of that illness with complications, then the incorrect coding will generate concern for the validity of the costs of that patient's care.  The difference in cost could be in the thousands making it appear that the provider was being wasteful and ordering services in excess of those needed for that coding level.  Aside from the practical problem that creates, it also invites a reevaluation of the physician's overall performance.  That could result in exclusion from a plan or a denial to participate in a desired shared-risk initiative.

While the importance of accuracy in coding is essential to the medical community in general, it is obvious that the onus for diligence is on the shoulders of the individual physician.  That being said, the impact of a physician's reputation can certainly affect the hospital or care facility with which he is affiliated.  Without a doubt, both the physician and care facility could quickly find themselves with denied access to networks or other potentially lucrative shared-risk organizations.

While keeping a physician's professional profile from over-utilization isn't generally a major part of the documentation and coding strategies for ICD-10, it's importance cannot be overstated. Proper reimbursement for services provided is certainly at the heart of accurate coding and will be even more important when ICD-10 is implemented.  The 'bottom line' and the protection of the provider's reputation demands it.

Healthcare Information Services recognizes the importance of all aspects of proper and accurate coding for our clients.