ICD-10 and its Impact on Prior Authorization

Prior authorization is now an integral part of the healthcare industry. With the implementation of the Affordable Care Act, the importance of prior authorization has doubled up. How does prior authorization help?  Prior authorization is an authorization or approval that a health insurance or plan requires their beneficiaries to obtain before receiving certain medications/treatment/tests/services. Prior authorization helps providers to release payment promptly and reduce write-offs while the patients can get their desired service without having to pay from their pocket. However, medical coding has a huge role to play in a successful prior authorization.

The Arrival of ICD-10

As healthcare is highly aligned with Electronic Medical Record (EMR) and Electronic Health Record (EHR), medical coders review clinical statements and assign standard codes. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the latest system used by physicians and other healthcare providers for classifying all diagnoses, symptoms, and procedures recorded in conjunction with hospital care through proper codes assigned against those. It's the improved version of its predecessor, ICD-9.

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Changes that ICD-10 has Brought to Prior Authorization

ICD-10 is a medical classification listed by World Health Organization (WHO) for the differential diagnosis, reasons, causes, findings, complaints, diseases, injuries, procedures, etc. Since prior authorization is now mostly based on procedural and medicinal codes, ICD-10 has been able to zero-down on the gaps by covering more and more medical requirements. ICD-10 is a great instrument for streamlining the prior authorization process enabling more prior auth approvals. An integral part of the patient-provider-payer cycle, ICD-10's accurate level of coding has come as a boon to the providers and the industry as a whole. However, practice managers have anticipated the following implications:

• Diagnosis Code: The importance of diagnosis codes is huge in prior authorization request approvals. The implementation of ICD-10 is expected to rise that to a large extent.
• Procedure Code: Monitoring the submitted ICD-10 codes against the requested procedure codes needs to be strict for better claim denial management.
• Training: Proper training programs for the prior auth executives have to be set to get them updated with the new procedures, associated codes, and the technicalities involved.
• Additional Information: ICD-10 requires providers and/or their prior auth requestors to gather more information on the patients and the procedures, definitely much more than before.
• Medical Coders: Medical coders need self-upgrading for an improved level of submission of correct diagnosis codes.

ICD-10 migration egged by these checks and balances is definitely helping prior authorization in the long run. The only flip-side is, payers will put more pressure on the providers with repeated checks and extra documentation for any slight deviation. This can get taxing for the already over-burdened in-house staffs. Taking help of the professional prior authorization services can solve this drawback.

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