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How Will PI & WC Carriers Handle Chiropractic Claims in ICD-10?

Friday, September 4, 2015   (0 Comments)
Posted by: Sheri Ryan
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Reposted from The Strategic Chiropractor Blog post 9/01/2015

Tom Necela, DC, CPC, CPMA, CCP-P 

One of the most common questions I’ve been getting at my ICD-10 Intensive Workshops is in regards to implementing ICD-10 with Auto Insurance Carriers (PIP, MedPay) and with Worker’s Compensation Insurance.

While everyone understands that Auto and WC carriers have a different relationship with you (the provider) than commercial payers, there appears to be some major confusion as to exactly what will happen when ICD-10 rolls in on October 1, 2015.

First, let’s examine the facts:

Why Auto and Worker’s Comp May Administer Their Chiropractic Claims Differently

First, in general, chiropractors are not contracted by either payer type (WC, PI) so right from the start, the relationship is different. There is no contractual obligation. In some cases, no published fee schedule. And the “rules” in many scenarios are different. While some PI payers choose to follow similar payment guidelines as Medicare, they are not required. Similarly, a WC carrier may publish their fee schedule if they choose; but they also operate on a different set of rules (and they generally police their own policies).

What this means for ICD-10 is that the coding scenarios may be slightly different for WC and PI than for commercial payers and Medicare.

Secondly, the “approved” code set can be entirely different as well. For example, a WC or PI carrier can limit the codes which are payable to a smaller subset of codes than even Medicare does…if they choose. Or they may allow more. It’s up to them.

Will Auto and WC Use ICD-10 At All?

Given that these two payer types are “outside the box” (at least compared to Medicare and Commercial Insurance), there has been considerable discussion as to whether auto or WC carriers will use ICD-10 codes at all.

Even if these carriers claim that they are non-HIPAA covered entities and not subject to ICD-10 coding requirements, there are a number of good reasons that indicate that they will adopt ICD-10 anyway. Here are a few:

  1. Simplicity – if the rest of the world is required to be on ICD-10, a WC or PI payer choosing to remain in ICD-9 will complicate claims processing as it attempts to force HIPAA covered entities (who are required to use ICD-10) to maintain two systems. Everything would have to be constantly converted and/or reprocessed to reflect two code systems – a mess that even a payer will likely want to avoid.
  1. Cost Effectiveness – given the complexity described in #1, a PI payer or EC payers insistence on using ICD-9 would eventually cost them more money. Over time, as ICD-9 fades away, there will be no need to update and maintain system the ICD-9 system – unless a payer were trying to use both. So, for cost reasons alone, it will make sense for the payer to drop ICD-9 and focus on one codeset.
  1. Communication Problems — Because of the inter-related nature of injuries, it will be necessary for even WC and PI payers to “speak” ICD-10 in the future. For example, a car accident victim may be sent initially to a hospital who codes everything in ICD-10 and then to a private physician who does the same.   If the auto insurance insists on ICD-9, a communication gap occurs. Similarly, with respect to subrogation or exhaustion of benefits, an auto carrier often defers to secondary payers to “finish the claim.” But in order to do so, those secondary payers must communicate with the primary payer to see what’s been done, what’s been paid for, etc. Obviously, then it is in the PI payer’s best interest to communicate using the same code language.
  1. State Rules – in terms of Worker’s Compensation, some WC carriers may be forced to adopt ICD-10 through state statutes and regulations, thus ending their days in ICD-9 along with the rest of us.


What You Won’t Likely See With WC and PI Carriers

While all the above may be good news for chiropractors looking to keep things simple in ICD-10, there may be one sticky issue that will remain.

Unlike Medicare, commercial payers, clearing houses and EMR systems who will all offer opportunities for providers to test ICD-10 codes in their systems, WC and PI carriers may choose to neglect testing.

Unfortunately, because they are not mandated (like Medicare) and because they don’t have contractual relationships with you (like commercial carriers) and because they are not looking to keep your business (like clearinghouses and EMR systems), there is little motivation for WC and PI carriers to offer testing. The one possible exception here is the WC Carriers who may be facing legislative requirements to test.

Apart from that, don’t be surprised if your average auto carrier does not offer you the ability to test your ICD-10 codes. But, on the other hand, you should count on them to use ICD-10 codes after October.


About Dr. Tom Necela & The Strategic Chiropractor 

The Strategic Chiropractor is a consulting firm founded by Dr. Tom Necela to help teach chiropractors to work SMARTER, not harder, on your practice through sound billing, coding, documentation, compliance and business strategies.

Tom Necela, DC, CPC, CPMA, CCP-P
The Strategic Chiropractor, LLC 
Phone (800) 577-0321
Fax (888) 508-8356

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