Staying Ahead of the Curve: Preparing for Upcoming Reimbursement Model Changes

By Ashley Carson, CPC, CCS-P, and Briauna Driggers

​As healthcare continues to evolve, so too do the models that determine how providers are reimbursed for their services. With an increasing shift from procedure-based payments to those that rely heavily on diagnosis coding, ensuring your practice is prepared for these changes is essential for long-term success. The ICD-10-CM diagnosis code set, once considered secondary to procedure codes in reimbursement, is now playing a more central role, making precise documentation critical.

The Rising Importance of ICD-10-CM Codes

​Traditionally, reimbursement payments have been driven primarily by the procedures performed. However, payers are developing new models that factor diagnosis information, making ICD-10-CM codes just as important in determining the level of reimbursement. This shift is expected to grow in the coming years, placing even more emphasis on accurate diagnosis coding alongside procedure documentation. Practices that adapt early will be better positioned to avoid financial disruptions and maintain a smooth revenue cycle.

Why Detailed Documentation Matters Now More Than Ever

Detailed, accurate documentation is not just about compliance; it’s the key to unlocking appropriate reimbursement. Incomplete or vague documentation can result in underpayment or payment denials, as it may fail to support the specific ICD-10-CM codes submitted for claims. As reimbursement models change, the specificity of diagnosis codes becomes increasingly significant. Documentation must clearly capture the patient's condition, including any contributing or underlying factors, in order to reflect the full complexity of care.
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The move toward diagnosis-based payments means that healthcare providers need to ensure their documentation is granular enough to capture the complexity of each case. For example, in pain management, documenting only the primary condition without acknowledging underlying chronic issues such as diabetes or hypertension could lead to reduced payments or missed opportunities for full reimbursement. This principle applies to many specialties, from radiology to pediatrics and critical care, where ICD-10-CM documentation can directly impact financial outcomes.

Practical Steps to Improve Documentation Practices

​To prepare for the future, healthcare organizations should focus on enhancing their documentation processes now. Here are a few strategies to consider:

• Develop a communications process/workflow for provider inquiries:  An open line of communication that lets the provider know there are either omitted or under-documented diagnoses or symptom information.  A written workflow or process is recommended to ensure the communication is not leading the provider to document specific words or phrases, but rather clarifying existing documentation shortfalls.
• Provide Continuous Training: Ensure that clinical staff are up to date with the latest ICD-10-CM coding guidelines and documentation best practices. Ongoing education can help prevent common documentation errors and improve coding accuracy.
• Conduct Regular Audits: Perform routine reviews of clinical documentation to identify areas for improvement. This can help catch inconsistencies and missing details that could affect reimbursement in the future.
• Leverage Technology: Utilize EHR systems to their full potential by optimizing templates and prompts that encourage detailed documentation. EHR systems can play a vital role in ensuring that all necessary information is captured during the patient encounter.

​By focusing on improving documentation, providers can stay ahead of the anticipated changes in reimbursement models and protect their financial stability.

Focusing on Documentation for Future Success

​As the healthcare industry moves toward more diagnosis-driven reimbursement models, the importance of thorough, precise documentation cannot be overstated. Practices that prioritize high-quality documentation will be better equipped to navigate the evolving landscape of reimbursement while securing appropriate payments for the services they provide. By refining your documentation practices today, your practice will be well-prepared for the reimbursement models of tomorrow, ensuring long-term success.