Our team has been tracking first pass payer payment rates since the start of ICD-10. We’ve compared those rates to an earlier period just prior to the initialization of ICD-10 and we have not seen a meaningful decrease in First Pass Payment.
We monitor claims that are rejected by the payer at the payer gateway (Rejections) and claims that are marked denied per the ERA (Denied). Claims that are either Rejected or marked by the payer as Denied are considered as not making the first pass.
Approximately 98 percent of claims sent electronically and where status is received electronically in a machine readable format are paid on the first pass.
Approximately 99 percent of claims sent electronically and where status is received electronically in a machine readable format are paid on the first pass when eligibility, provider and payer data in the claim are correct.
No significant change in First Pass Rates were observed after the switch to ICD-10.
The Bottom Line
- Check Eligibility + Correct NPI for Credentialed Doctor = Approximately 99 percent First Pass
- Little to no impact on First Pass Rates related to ICD-10
*Caution: Payers have been following Medicare’s lead on allowing less specific codes in favor of codes in the same family during the current one-year “honeymoon period.” Look for an EHR that helps guide you to the most precise code appropriate for the clinical presentation of your patient so that you don’t see any significant changes after this one-year grace period. Make sure that your system has an easy way to map ICD-9 to the more specific code that the payers will require in the coming months. We have unique algorithms and search capabilities that have already proven to be successful in matching ICD-9 to the most specific and appropriate code for the patient’s clinical condition.