Healthcare Economy

Let’s first look at the issue from a provider standpoint. Providers will start capturing the ICD-10 codes for clinical purposes on Nov 1st 2014. But in most likelihood, contracts would be on ICD-9 and so the charges will need to be submitted on ICD-9 based DRGs. Later, at some point in time, few contracts will be on ICD-9 and remaining on ICD-10 – the charges will need to be submitted on both code-sets during this period. To be able to submit the charges on both code-sets the providers will need the ability to capture and store both code-sets based on the payer that the claim needs to go to. At the point of service, capturing both codes for the same service might not be a big challenge.   

The problem is more severe on the payer side. Payers have no easy way of knowing the ICD-9 as well as ICD-10 codes for the same service. Payers will need to pay claims and send remittances on the codes they receive. They’ll need to pay claims based on a code-set that’s in the contract. Maintaining one set of adjudication rules wouldn’t work. Crosswalks wouldn’t work either, partly because crosswalks can’t guarantee 100% conversion. The other reason is that practically speaking, crosswalks can’t be used in every rule of the adjudication process. So, dual adjudication platforms will need to be maintained for the transition period.

Given these complexities, the dual processing issue is at the top of my list of challenges with the ICD-10 transition. Backward compatibility and historical data support requirements make the issue more convoluted. And now I’m beginning to wonder if the so called “neutral strategy” for ICD-10 transition is practically feasible at all.