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Tips and Tricks: Navigating Payer Contracts in Your ICD-10 Prep

As the ICD-10 transition draws closer, practices are beginning to focus a lot of attention on staff education and training efforts, which are essential to a smooth implementation. Yet even in the midst of all your other ICD-10 preparations, don’t forget to spend some time focusing on the diagnosis codes within payer contracts.

One of the best ways to ensure you’re not losing out on rightfully earned revenue is to engage in periodic contract re-negotiations, since the financial health of every practice depends in part on the ability to negotiate favorable contracts. Payer policies and CPT code relative value units (RVUs) change frequently, so it’s even more important to review these periodically to make sure your contract is up-to-date.

Despite the fact that CPT codes are considered an integral element of most ambulatory contracts, practices tend to overlook the role that diagnosis codes play. Denial reports configured based on diagnosis codes, for example, can provide powerful data.

Before reaching out to payers to discuss contracts, you should review those claims that have not been reimbursed by the payer. Oftentimes, there are specific diagnosis codes tied to the payer’s medical necessity and/or policy denials. Your clearinghouse can help you gather this data by service and by payer, so you can gain a better understanding of potential areas of revenue loss.

In addition to your standard payer contracts, also review any pay-for-performance agreements your practice has signed. These agreements may rely on diagnosis codes to an even larger degree.

With the increased specificity of the ICD-10 code set, providers will be able to describe more accurately complex patient conditions, especially for patients with multiple chronic conditions. Keep an eye on contracts and diagnosis codes—they might be the justification you need to request higher fees in the future.