It’s Déjà Vu All Over Again

With more than a full year under ICD-10, it seems it is reasonable to expect local coverage determinations (LCD) to be current and correct.  After all, everyone in the industry knew there were errors and omissions in some national and local policies.  Many had already been pointed out.  And yes, some have been corrected.  The expectation was that contractors and commercial payors would take the initiative to review all their publications and make necessary corrections.  Not only has that not been done universally, but it appears more errors have arisen in the October 2016 updates.

It also appears the onus is on providers and their representatives to find the errors, notify the contractor of the problem through a formal LCD reconsideration process, and wait for a response to the request to learn whether corrections will be made and if they will be retroactive.  In fact, one contractor explicitly stated they would not review their policies unless an error was pointed out through the reconsideration process.

Just a few examples of LCD issues include: coverage for the initial and subsequent encounters but no sequela codes, the entire category of collapsed thoracic vertebra was omitted, no pregnancy related respiratory diagnoses, the entire category of displacement of bone devices, implants and grafts was omitted, cardiac pacemaker covered services omit certain parts of the pacemaker, October 2016 codes with expanded descriptions were completely deleted when the “parent” code was no longer valid, and the list goes on.

In reality, providers and their representatives may not immediately identify key omissions or errors for myriad reasons.  They may provide a new service or see a new and different patient population, a third party revenue cycle management company may begin coding and billing for a new client specialty, the specific disease, disorder, sign or symptoms may not have been documented in past cases, the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 have added or modified coding instructions, clinical documentation improvement changes historical coding, etc.

Based on some industry reports over the last year, these issues raise the concerns of reporting accuracy.  Will less or inaccurate codes be designated when the correct codes are not covered due to policy diagnoses errors and omissions?

While providers certainly must take responsibility for evaluating coding related issues and denials and address them as necessary, the contractors and commercial payors also have an obligation to accurately update and monitor their policies for errors, oversights, mistakes and omissions.  For the contractors and payors to place the onus on the providers not only to find the issues, but to request reconsideration seems to be shifting what is a clear responsibility to someone else.

It is disconcerting that providers are expected to know and comply with every law, rule, policy and guideline or risk what are potentially very punitive results, but the same high standard does not appear to be required of the contractors and payors.

With rare exception, providers are doing their best to provide quality, cost effective patient care while being inundated in operational and regulatory requirements.  Asking them to perform free quality assurance for contractors and payors is unreasonable.  Let’s place the accountability and responsibility where it really belongs.


Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.

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