With the transition to ICD-10, payers will certainly leverage the added granularity to improve their existing policies, adjudication rules and benefit categories. So, now certain services will be covered and paid, while others will no longer be covered and might be pended or denied if the claim is filed. These decisions will be crucial during the transition from ICD-9 to ICD-10 because any loss or misinterpretation of information about clinical issues will invariably distort the ability to ensure neutrality with respect to claims payouts. We also know that payers do leverage certain software (DCG/MEG/DxCG/CRGs) to predict their member expenditures or prospective provider reimbursements for members with multiple, combination or complicated conditions. These prediction software systems (which are all in ICD-9 as of today) will be migrated to ICD-10. Lack of clinical coherence in their transformation process will invariably alter the coverage group and risk pool definition, along with the member risk profiling and stratification statistics - all of which will ultimately impact the bigger goal of achieving financial neutrality at an enterprise level.
Please read the complete article in my blog post at ICD10HUb.com.
The diversity in the nature of ICD-9 to ICD-10 coding means that the task of developing a workable translations and crosswalks is highly challenging and complex. To my opinion any healthcare organization that tries to address all of them only through GEM is at significant risk of paralyzing itself. A thoughtful and rational approach is essential to derive the best from the out of the box maps available in the GEM. But that cannot happen without availability of reference clinical data.
You’ve read about why ICD-9 to ICD-10 crosswalk is going to be needed during the dual processing period! You are probably also aware that any crosswalk will require additional data to be able to zero in on a single ICD-10 code corresponding to an ICD-9 code. So, what is this additional data? Where will you get the data from? Will whatever you are able get, be sufficient for effective crosswalk?
CMS has used the opportunity brought in by the increased specificity of ICD-10 codes to increase the granularity of DRG codes. This will help CMS streamline Medicare payments. Since significant number of Medicare and commercial claims is paid based on DRG codes, the added granularity is bound to cause uncertainty around provider reimbursements. This uncertainty combined with the payment reductions under SGR (Sustainable Growth Rate) has the potential to significantly impact providers’ bottom-line. Payers are not immune to the impact either. It’s crucial that payers and providers simulate claim payments, compare the payouts between I9 and I10, and be better prepared for the change.
The necessity for dual processing with ICD-10 is not just a result of interoperability between entities on disparate code-sets. Even if we assume that all the payers and providers are migrating to ICD-10 (desirable, but hardly a pragmatic situation) on Oct 1st, 2013 (compliance date), dual processing is going to be required for some adjusted claims and inpatient claims.
Bad news first… HIPAA 5010 has nearly 1,000 unique changes. Some of these changes (like expansion of patient last name alone) could have thousands of impact points across your applications and databases. Overall, the number of impact points could easily run into a couple hundred thousand for an organization of average size. The direct and indirect impact of these 1,000 changes on the IT systems needs to be analyzed as the first step in the 5010 transition journey.
Is there too less time for ICD-10 transition? Or is there plenty of time? Will my vendor ensure that we’re compliant, or should we engage a consultant to do a thorough gap assessment? These are questions that should be and probably are on every program manager’s mind that’s been entrusted with the ICD-10 implementation in his organization.
In the ICD-9 era, the ICD Codes were small in number, though not highly organized as ICD-10 is. Given that the ICD-10 codes bring in the granularity and accuracy to the diagnostic and procedure coding, not to mention decades of familiarity of the coders in ICD-9, how does a provider ensure that these codes are coded correctly?