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ICD-10: Payers & Providers Need to Get Along

On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10). HHS is seeking comments by May 17.

The proposed rule extends the deadline for use of ICD-10 code sets used in claims management and medical billing from October 1, 2013 to October 1, 2014, responding to providers concerned with the difficulty of implementing the new edition in the time provided. AHIMA and HIMSS are urging us to “stay the course” with our implementation planning. I agree.

Payers and Providers do not always have alignment of their own internal business and IT. Payers and Providers are not always in agreement with each other’s medical policy that will be used to defend a GEM. Payers and Providers are not always in agreement with each other’s perspective of benefit and reimbursement. Now let’s scale up from 17,000 ICD-9 codes to 155,000 ICD-10 codes…

Payers and Providers Need to Get Along

The clock is ticking, and we’re still trying to define neutrality before we can even start to build processes to verify neutrality, and then we need to re-contract…

The Workgroup for Electronic Data Interchange (WEDI), an industry advocacy organization, conducted the survey in February and has submitted results to the Centers for Medicare and Medicaid Services (CMS). Based on the premise that ICD-10 impact assessments should have been completed in 2011, the WEDI survey results find:

  • Nearly half of providers did not know when they will complete the impact assessment;
  • More than a third of insurers had completed their impact assessment and a quarter of them were less than halfway done;
  • One-third of providers expected to begin external testing in 2013 and one-half did not know when the testing would start;
  • Most insurers do not expect to begin external testing until 2013; and
  • About half of surveyed vendors were less than halfway through with their product development.

In order to start making sense of the ICD-9 to ICD-10 code variability risk, payers and providers must consider the following:

  1. Need for process to evolve medical policy to defend the clinical equivalency mapping of ICD-9 and ICD-10 codes ongoing
  2. Need for identification of ICD-9 codes within software application logic, then remediate or replace systems as required
  3. Need to end-to-end claim adjudication, benefit assignment and reimbursement variability testing as foundation for Payer/Provider re-contracting

Internal Business and IT need to get along.  This is not typical SDLC.  Testing sooner rather than later will allow for the re-introduction of test results within each iteration of process refinement. Organizations need to embrace collaborative and dynamic requirements management.

Organizations need to pick partners wisely.  You can’t outsource accountability for compliance through vendors and hosted solutions.

Adjudication, benefit assignment, reimbursement schedules and re-contracting can happen later.  Let’s make sure we don’t miss the mark on our assessment of clinical equivalency. Medical policy will provide context for defending our GEM, but we’ll still need to verify through testing. Even though HHS has proposed a 1 year reprieve,  Payers and providers need to get to the table asap.

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2 thoughts on “ICD-10: Payers & Providers Need to Get Along

  1. Mike Berard Post author

    Steve, your perspective is appreciated. Regarding “medical policy first”, I’d definitely advocate simultaneous or even parralel attention to adjudication, benefit assignment, reimbursement schedules and re-contracting as it relates to “operationalizing” an ongoing environment of change. The point I’d like to emphasize is that GEMs will drive business process refinement and business rule development. Changes to GEMs will translate into downstream change to business rules and application logic.

  2. Steve Sisko

    Internal business and IT need to get along is right! I worked on the IT-side of an ICD-10 project where business analysts and we “systems analysts” seemed to constantly be working on the same issues and duplicating work – except when we weren’t and then neither side was eager to accept responsibility. There was a lot of “that’s not our area” being passed back and forth. Sometimes no one knew what the need or issue was but everyone knew it wasn’t their responsibility. :)

    One statement I don’t necessarily agree with is “focus on medical policy first”and “Adjudication, benefit assignment, reimbursement schedules and re-contracting can happen later.” Unless later is meant to be “later in the period leading up to 10/1/14.” I would argue all these areas are all closely interrelated and can/should be addressed simultaneously. I believe there could be two phases of medical policy, benefit, contract and adjudication reconfiguration: an immediate phase to meet the transition and maintain as much neutrality as possible and a post-implementation phase where ICD-10’s increased granularity can be used to really fine tune and differentiate benefit, contract and claim processing capabilities. The latter phase not effectively performed using GEM outputs.

    In any case, time is a wasting.

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