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Mutually Mandated ANSI X12 275 is the only means for Payers to develop an agile CROSSWALK

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.

Looking at the industry pulse, it is evident that providers are sluggish in complying with ICD-10 by the mandated timeline. As HIPAA 5010 also accommodates ICD-9, Providers can take this advantage to send out claims in ICD-9 post October 2013 till they are ready with ICD-10. Going with the mandate, Payers in such situation can simply opt to deny payments for all ICD-9 based claims. But that won't be a wise business decision, as in that case they might end up losing potential Provider clients.

A generic frequency based ICD-9 to ICD-10 mapping can be an intermittent solution to serve the purpose of reimbursement. But such a map may not be intelligent enough to assign an accurate dollar amount to the provided ICD-9 coded clinical diagnosis/procedures in the claim. Simply with such a frequency based crosswalk, Payers will fail to derive the financial incentives of ICD-10 that is promised by its clinical granularity & specificity. Even tackling the issues like detection of fraudulent claim would be still challenging for Payers, as before. Frequency based map will also fall short in defining precise crosswalk for all ICD-9 based historical data, that will be required to re-strategize their allied business lines e.g. Disease management, Utilization management. This is why Payers needs to look forward in creating a clinical data referenced agile crosswalk that will serve across the spectrum of their business.

It's true that unlike Providers, Payers doesn't have any in-house clinical data source, but that does not mean that it's too difficult for them to develop a clinically sound crosswalk? To best of my knowledge, there is a potential means for Payers to get access to clinical information and develop their own intelligent crosswalk. They just have to turn back and make a rational judgment in mutually mandating the existing ANSI X12 275 Claims attachment transaction with their trading partners.  Even to adjudicate claims with insufficient information, payers today do seek for an X12 275, then why can't payers make it a compulsion now with every incoming 837?

So far the considerable animosity between health plans and providers have been a bar in turning the 2005 published NPRM [45 CFR Part 162] to a final rule, which intended in mandating the EDI X12 275 transaction among the covered entities. But it's now the time for Payers to lead from the front in resolving the existing debates. Mutually mandating the EDI X12 275 with the Providers/trading partners can aid Payers to fetch adequate reference clinical data. Converting the clinical data that comes in a XML format as per the HL7 (CDA) standard or scanned images through EDI to a human-readable format and parsing them through a GEM based ICD-10 code mapping tool powered by intellectual clinical rules will certainly produce a simple, clinically intelligent, business agile ICD-10 crosswalk for payers.

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