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ICD 10 – processing adjusted claims

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.

Assume that a claim with service date prior to the compliance date was rejected by the payer post compliance date, due to incorrect coding. The provider must code the claim correctly and resubmit it to the payer. If the provider’s coding and billing systems can’t support ICD-9 codes anymore, the claim can only be submitted manually. Of course the product vendors are aware of this problem, so their billing systems will continue to support ICD-9 codes beyond the compliance date.

Ideally, product vendors will allow users to capture ICD-10 codes (regardless of the date of service) and internally (within the coding and billing systems) translate to ICD-9 based on the date of service. But the vendors might also provide limited support with two sets of UI’s, one to capture ICD-9 and another for ICD-10 codes, leaving it for the coders to decide which code-set and UI to use. The first option will naturally be desirable - the providers would use some kind of a crosswalk or VOSER software to convert codes in this option.

On the payer side, adjudication programs will need to base their logic on contract term effective dates and the dates of service (DOS). If the DOS or the discharge date (for inpatient claims) is prior to the compliance date, the adjudication programs will pick up the contracted rates that are based on ICD-9 codes (and matching DRG and CPT codes). Otherwise the ICD-10 rules will apply. The codes that are used by the adjudication programs will flow in to the claim output process, so the remittance process will not require major revisions. The remittances will automatically reflect the correct coding.

Finally, when the remittance is received back by the provider, payment posting will take place using the code-set that was originally used to submit the claim.

The following diagram illustrates an arrangement that will work while processing adjusted claims.



The bigger challenge with respect to dual processing of ICD10 codes is during claim reimbursement. Not many payers would try to get the ICD10 reimbursement mapping avaialable by the Mandated date of October 2013. There will be payers rate engines still using the ICD9 codes for payments and typically have to convert ICD10 code to ICD9 for reimbursement. This will have a bigger challenge to determine the date of service, convert the code and pay the claim. IF this claim is coming back for adjustment there are another set of rules to be defined on how to process such claims. We need a business mapping on type of claim, what will be the reimburment mapping codes and when will they be converted and what is the conversion logic based on claim type in-patient and out-patient etc.

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