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Posts Tagged ‘4010 to 5010’

AHIP 2012 Conference Trend Watch

The 2012 AHIP national conference is almost upon us.  Our team will be at the June 20-22 event in Salt Lake City.  With all of the changes we are witnessing in the health insurance industry, this year’s conference promises to address the many needs of conference attendees.  Whether it is meeting regulatory compliance issues or preparing for health insurance exchanges, the AHIP conference will be the place to be this week.

Participants should leverage the AHIP conference to attend many of their peer organization presentations to learn from personal experience.  We look forward to visiting the exhibit floor to listen and observe what is being highlighted by the vendors as well as what our peers are saying and asking.  Health insurance companies can use this information to formulate how to address important issues.

Most importantly, enjoy the educational and collaborative nature of this event and network with your colleagues and solution providers so you can see the potential that can be achieved.  Take advantage of intelligence and expertise that will be found in Salt Lake City this week that will enable your health insurance system to be among the world-class organizations.

We would love to meet with you at the conference.  Leave a comment, catch up with us in person, visit our AHIP page, or contact us on Twitter (@Perficient_HC) to discuss what you think the hot topics for health insurance are this year.  Here is what we think:


Perficient provides a competitive advantage for health plans looking to capitalize on the opportunities related to regulatory compliance investments, Health Information Exchange (HIE) initiatives, and health reform legislative mandates.

  • Healthcare Payer Shared Services Platform: Standards-based, secure connectivity platform for the exchange of health information across constituents, business units, and external trading partners
  • Automated business processes: Streamline IT architecture and speed implementation
  • Operating Cost Reduction: Transitioning transactions to the new platform, thereby eliminating the need for overpriced service providers
  • IT Maintenance Cost Control: Significantly reduced costs through the replacement of a heterogeneous Oracle/Sun Java and SeeBeyond middleware with a standards-based WebSphere implementation
  • Faster Time-to-market: Over three months’ savings per shared service leveraged for new applications
  • Improved Business Productivity: Due to increased operations visibility and system recovery capabilities


Perficient’s HIPAA 4010 to 5010 solutions are a full scope effort within your organization including:

  • Assessment: Identify the tools and technologies that best fit your environment. Clarify the benefits and opportunities you can expect. Define the people and process changes that will facilitate a 5010 upgrade program
  • Solution Roadmap: Define an actionable roadmap that clearly articulates the steps required for a successful upgrade. Align to business goals while mitigating risks
  • Implementation: Execute this roadmap with a flexible project approach. We work in concert with your team to deliver results at lower costs than our competitors
  • Business Process Improvement: Improve business processes for electronic data transactions (824 – application reporting, 820 – premium payments); transaction reprocessing and transaction management; new stricter enforcement of the HIPAA legislation; new regulations convert business associates as covered entities under HIPAA


Perficient’s ICD-10 solution begins with a phased roadmap of coordinated projects beginning with a careful analysis of your healthcare IT applications and ending with the cultural transition of using the expanded code set.

  • Impact Analytics: Automates the identification and visualization of relationships between ICD-9 in historical claims data and corresponding ICD-10 code matches with eight separate levels of complexity and risk
  • ICD-10 Code Management: A medical ontology based code management system that allows modeling and mapping of ICD-9 codes into ICD-10 equivalents, and vice versa
  • ICD-10 Test Management: Automates the creation of large volumes of ICD-10 test data and shows the differences between results processed in ICD-9 and in ICD-10
  • ICD-10 Code Translation: A scalable, high-performance translation engine that enables ICD code translation (forward/backward)
  • ICD-10 Consulting Services: Provides expert support for the software toolset and services

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.

ICD-10 at at the Half Way Point: How Prepared are Healthcare Providers?

In 2010, a study was conducted by Georgetown University and Booz Allen Hamilton to define trends, challenges and lessons learned surrounding the implementation of ICD-10 and to provide actionable information to serve as a resource for organizations navigating the transition. The participating health care organizations were large hospitals, integrated health care systems and other national leaders who were likely to have initiated the process far in advance of the October 2013 deadline. Interviews were conducted with employees of seven health care organizations in March and April 0f 2010. Among the trends and challenges identified by these organizations identified were:

  • Each organization had appointed project managers and steering committees to monitor the transition
  • Five organizations were in the early stages of impact assessments
  • Five of the organizations had yet to budget significant funds
  • The organizations reported difficulty creating a sense of urgency among staff concurrently dealing with the transition while managing other recently implemented regulations
  • Four organizations reported difficulty in raising awareness among physicians
  • One organization reported difficulty locating timely and accurate information about the transition
  • Three organizations reported difficulty staffing the transition

Fast forward to a KLAS survey of 163 health care providers conducted in October 2011.  Progress in the intervening time has apparently not been significant particularly in some of the same areas identified in the 2010 survey.  The KLAS survey found that less than ten percent of healthcare organizations are over halfway to being fully prepared for ICD-10. A lack of understanding regarding how extensive transition to ICD-10 is persists. And while most know the transition will be costly, the survey also found that many providers had yet to establish an ICD-10 budget.

Across the organizations surveyed, more than half of the respondent (54%) indicated that training was their number one concern and physician and nurse readiness also ranked high at 44%.  Nearly two thirds (65%) of organizations also expect to use 3rd party firms to help them prepare. The longer they wait the more difficult and costly it will likely be to find qualified resources.

Possibly in response to this widespread lack of preparedness, as well as pushback by the American Medical Association, Marilyn Tavenner, Acting administrator of the Centers for Medicare and Medicaid Services (CMS) announced at an American Medical Association conference held in Washington, DC on February 14, 2012 that CMS now intends to re- examine the timeline for the switchover to the new code-set.  A key factor may be current problems implementing the 5010 transaction set which is a prerequisite for ICD-10. The Medical Group Management Association (MGMA) also recently asked CMS to postpone enforcement of the 5010 set to June 30 because a large number of physicians are encountering payment delays due to the transition.

Regardless of deadline, for some organizations no amount of time will ever be sufficient. As the deadline draws closer the pushback is likely to continue and potentially increase in intensity.  Should CMS implement a delay? If so, how long is long enough?    

“The Tipping Point” – What one CNO shared with me at HIMSS

Looking back at the last two days of meetings, panels, vendor meetings and sharing I met up with a very close colleague of mine who is one of the brightest CNO’s I have ever met.  Mary Jo and I decided to grab a bite to eat and digest what we saw and learned these past two days at HIMSS.

Mary Jo had a ton of stuff to get off her chest, so I ordered a bottle of German Riesling wine (our favorite) and asked her, “So what is on your mind?” Mary Jo took a look at me and said, “Are you sure you want me to share? I’ve got a lot on my mind and after these last two days I am now truly concerned about what we do when we both get back to work…”  I poured the wine and got comfortable – and boy was she right, she had a lot on her mind.  She started with:

“As we approach revolutionary changes for healthcare policy in the U.S., the industry itself is undergoing complex and confusing changes, many of which involve information systems. The use of IT in medicine has grown in the same way it is growing within the larger cultural landscape: technology is everywhere and though we are not sure what tools may come next, we do know that it is a mainstay. My problem, Steve, is that my nurses and doctors are not prepared to navigate all this change AND take care of their patients!

Information systems in health care practices have not just penetrated the exotic sciences of biotechnology and nanotechnology. The use of database management systems, network-based infrastructures and the significant growth of web-based systems- all paired with recent government legislation- is part of an industry-wide boom that will forever change the landscape of health care practices and administration. We are headed for the Perfect Storm.” Read the rest of this post »

ICD-10 on the Floor of the Conference: What’s the Buzz all about?

What a Day!  I have come to view HIMSS as the source for what’s happening in healthcare.  Today was not different – the floor of the conference was abuzz with folks asking (in almost a whisper):

“Will ICD-10 really be enforced by CMS come October 1st, 2013?” 

“Will we really need to have all of our systems switched over to accommodate ICD-10?”

And my favorite: “CMS will grant extensions to Providers – right?”

As I wandered through the maze we call HIMSS 2012, booths that featured anything to do with ICD-10 Assessment, or Remediation, were packed (ok, it is HIMSS) with people needing the answers to these questions.  As I listened to the questions and responses I began to realize that the folks asking the questions were looking for answers that relieved their fears and anxiety – too bad, they will not get the ’right’ answers they were looking for.

I say this not because I have a crystal ball and looked into it, or that I am in the know I know the answers because I heard these same questions last week in a Town Hall conference call with Congresswoman Jackie Speier.  In this Town Hall meeting, there were a number of healthcare executives asking the above questions expecting Ms. Speier to save the day and share what CMS was really going to do and when.

One could hear a pin drop (and on the phone that is quite difficult) waiting with bated breath for the answers.  What we heard was not what was expected…

To the question: Will ICD-10 really be enforced by CMS come October 1st, 2013? – the answer was a soft-spoken, but clearly pensive response: Yes, the CMS mandate will be carried out as stated by CMS at this point in time. This could be taken in any number of ways, which was, from my perspective, what she wanted (or needed) to say. After all, she does not have a crystal ball either.

To the question: Will we really need to have all of our systems switched over to accommodate ICD-10?  This was a question Jackie could not answer, but she did her best by handing it off to her go-to guy at her district office.

He addressed the question by backing into it – he began by clarifying that if CMS is going to need all claims submitted in ICD-10, it would appear “common sense” that a hospital would need to make sure they were prepared to file any claim in ICD-10 format.

At the completion of his response, it was as if the phone line was cut – the person asking the question thanked “Mr. Go-To Guy” and I guess was either out of questions or stunned by the response…

To the question: CMS will grant extensions to Providers’ – right?  This was an easy question for the Congresswoman to answer., Her response was the same I have given when asked a question dealing with the future: “It depends” was Ms. Speier’s retort. Then she gave some pithy examples, however as the caller continued to want a definitive answer, the Congresswoman continued to hold the line: “it really does depend on many factors that we to take into account.”

Oh well, so much for getting answers from the horse’s mouth.  Perhaps tomorrow as I roam the HIMSS Conference floor, some in the know vendor will have the right answers – I guess “it depends” on who I ask…

Creating your EDI mapping layout

In the previous blog we discussed the importance of knowing your data and business requirement needs. This is one place where that becomes important. If you already know your needs it makes it much easier to start your data mapping.

First you should contact your trading partner. They should have some type of functional specs which state what they expect to send to you or receive from you  or these are specs they will request from you.

Let’s begin with the layout of the transaction set for outbound data. I have found that the best way to start is to take the segments of the transaction set and put them in an Excel spreadsheet, keeping in mind to maintain the segment looping structures. Once you have the segments in your document you can then flesh them out further by putting in the individual data elements and sub-elements for that segment. As you are doing this it would be a good idea to mark each data element as to whether or not they are required, optional or situational. This will help you determine what needs to be present when creating the final product.

Now that you have the transaction set laid out in an editable format you can start marking those fields that fit the identified business needs. You can now use this document to cross reference to your trading partners’ specs as well. Keep in mind that if the data element states it is a required field you must have it populated with data.

Once this layout is complete it is time to start cross mapping to your database. Chances are you will be mapping to numerous tables based on the database layouts where each business unit utilizes their particular data, etc. These should all be reflected in your document and you should be working with your database administrator to make sure everything is being placed into or pulled from the proper table and field as well as whether or not any additional fields will need to be added to the database tables.

Now that you have your document complete you should review once again with the vested parties to make sure everything is as expected. This is a good time to identify any additional requirements or changes that need to be made before you start the actual mapping process.

You are now ready to start working with the mappers to create the transaction set.

Facing and Overcoming the 2012 #HealthIT Challenges Amidst the End of the World – Part I of 2


Healthcare providers and eligible primary physician practices are undergoing analysis paralysis because of all the government impositions on improving healthcare with the following list of complex problems to solve: HIPAA’s Version 5010 conversion, ICD-10 migrations, Meaningful Use (MU) of EHRs and Attestation , Accountable Care Organizations (ACOs) , Data Aggregation and mining for successful Quality Measurement Reporting and Performance Improvement Requirements, CPOE implementations, CDA and the CCD template based document generation for sharing patient information between health providers, Natural Language Processing (NLP), Private Health Information (PHI) in the Cloud, internal demand for emerging technologies, the Mayan prediction of the end of the world, Et cetera, Et cetera, Et cetera.

The list above is not a bloated aggregation of current buzz-words, terms, solutions and a potential world event, but actually projects (challenges) that most healthcare providers, large and small, have had to embark on or are getting ready to do so beginning the first quarter of this year; yes indeed, that is NOW!

The aforementioned list isn’t exhaustive either, because there are other very specialized areas that the ARRA/HITECH and the Affordable Care Act have intentionally or unintentionally triggered off as well.  We will leave a discussion of this topic to another blog in the near future.

Those organizations that have been proactive and early starters or pioneers have a clear advantage over the others but yet they’ll still face their own challenges and probably very similar to the late bloomers.

Any of these challenges (which are also projects by nature) involve not only unique but also many common complexities such as:

Format:        Challenge Level of Effort (1 = Least – 5 = Most)

  • Stakeholder alignment 2
  • Project Management 2 (communication, charter, schedule, resources, Et cetera)
  • Multiple vendor selection 4
  • Heterogeneous vendor alignment 5
  • Multiple potential software system and hardware upgrades 4
  • Reliance on Subject Matter Experts (SMEs) 4
  • Managing Disruptive Emerging technologies (e.g., mobile apps, tablets) 3
  • Workflow and process re-engineering 4
  • Compliance with HIPAA and possibly the FDA 3
  • Individual State laws regarding patient privacy that go beyond HIPAA requirements and constraints 3
  • Testing, Verification and Validation 3
  • Documentation 2
  • Training 2
  • Et cetera?

Read the rest of this post »

Were you ready for HIPAA 5010?

Hopefully everyone answered ‘yes’ and you had a smooth transition.  In this blog we will discuss some of the items we need to keep in mind when either transitioning or implementing EDI.

Whether you are getting ready to transition to a new standard or initiating EDI for the first time, remember the most important thing is to KNOW YOUR DATA NEEDS!

Knowing what data you expect to send and receive is one of the most important items you can establish.

First, review the standard for the transaction set(s) you want to use (some of the transaction sets used for healthcare are 835, 834 837, 270/271, etc).  Whether this is for Healthcare, Automotive, or any other standard, this is very important.  This will give you an idea of what data is available and what you can plan to accommodate.  Remember, just because it is in the standard does not mean you need that piece of data.

Once you have reviewed the standards, you need to get everyone involved: business users, a data mapper, a database administrator, trading partners and anyone else who might have a vested interest.  It might surprise you as to what data they will actually need and utilize.  Whether the data is used in the data warehouse or for reports it is important to identify your business needs.  Also, try to plan for future business requirements.  Just because you don’t use that piece of data right now doesn’t mean you might not need it as standards evolve.  You can start with a “wish list” and pare it down from there.  Keep in mind that just because you want to receive a particular piece of data, your translation software may not currently be set up to capture, your trading partner may not be able to accommodate, or your clearinghouse may not have that set up in their maps.  We all would like to have everything, but it is not always practical.

If you are converting to a new standard this is the chance to change things.  Just because it has always been done that way is no reason to continue – that may not be the best practice.  This gives you a chance to make things better and perhaps correct things that were not working right before.  If you are initiating a new transaction set, this is the perfect opportunity to grab the data you need and get everything set up right the first time.  This is where it is important to get the users involved.  As the person doing the research you may not think a piece of data is important, but to them it may be very necessary.

When you have identified all your data needs you are ready to move on to the next step – mapping the fields in the standards to your database.  We will talk about that in our next blog.

Have you initiated EDI? What data issues did you face? How did you overcome them?

ICD-10 Systems Remediation: The Countdown is on

In preparation for satisfying the ICD-10 medical diagnosis and inpatient procedure coding on October 1, 2013, Healthcare organizations will need to indentify all instances of ICD-9 codes that are maintained within the application logic of supporting business systems as a component of their ICD-10 Compliance Agenda. Impacted systems will include, but are not limited to, core claims administration, including the assignment of benefit to claims. Healthcare organizations must verify all business processes, data stores, applications, interfaces and reports impacted by the change to ICD-10. All systems that capture, store, send, receive, or edit diagnosis or procedure codes must be modified to accommodate ICD-10. And the clock is ticking…

In addition to claims and benefit administration, ICD-10 has the potential to impact enrollment, eligibility, adjudication, pricing, underwriting, medical management, case management, provider payment, provider contracting and more. Systems remediation must consider people, business processes and technology when assessing the scope of ICD-10 change.

What’s the Holdup?

Often, Healthcare organization “Business Areas” and IT Departments do not have service level agreements (SLAs) to govern the systems remediation functions of scenario, case, requirements and test management.  In the absence of SLAs, Healthcare organization IT departments, as internal service provider to Business Areas, often fall short of delivering services that meet Business Areas expectations of change timeliness and minimized cost, as well as accuracy and performance of development and remediation support.

Frequently, Healthcare organization Business Areas fall short in providing enough detail to scenarios, cases and business requirements to enable IT to define acceptable technical specifications to guide development and remediation support.

The traditional change management challenge is the development of effective internal collaboration between business owners, who are accountable for performance and integrity of execution of business process and IT, which are accountable for enabling business process through the use of IT.

Now, more than ever, Healthcare organizations demand the bridging of the gap between business area expectations and IT delivery of services. We don’t have time to wade through the layers of internal political distraction while the ICD-10 Compliance clock is ticking. If you already subscribe to the transition from Waterfall to Agile development, you’re half way home…

Collaboration’s Key Role

The next step is to evolve traditional change management through the development of a dynamic environment of collaboration that will directly support systems remediation through web-based dynamic workflow, cueing and messaging, in support of building a role and permission based system for the development of use scenarios, use cases, user requirements and test outcomes definition.

The reality is that the use of a dynamic environment of collaboration between business and IT is not limited to ICD-10 Systems Remediation.  Business and IT collaborative effectiveness needs to be woven into the fabric of organizational culture ongoing. This is not a one and done exercise.  The only thing missing is the method, approach, process and enabling tools to ensure repeatability and sustainability.

At what stage is your ICD-10 conversion? What tools are you using?

Semantic Web Technologies for ICD-9 to ICD-10 Conversion

ICD-10 code mapping is not for the faint at heart.  With a ten fold increase in the pure volume of codes, healthcare organizations will need a few tricks up their sleeves to pull this off.

The mapping between ICD-9 and ICD-10 in many cases is not a simple 1:1 mapping.  For example, ICD-9-CM code 274.02 “Chronic gouty arthropathy without mention of tophus (tophi)” can map to 97 ICD-10-CM codes for a greater level of specificity, e.g., M1A.3120 “Chronic gout due to renal impairment, left shoulder, without tophus (tophi)”. 

Going from a 4010 to 5010 transaction requires going from the ICD-9 code to a (usually) more specific ICD-10 code.  Based on the example above, assume we’ll need to map 274.02 to M1A.3120.  As the 274.02 doesn’t indicate that the gout was due to renal impairment or that it was in the left shoulder, we might need to find this information from multiple sources.

ICD-10: The Complex Logic Game

You can write custom code to pull this information together, but of course there may be thousands of conversions with complex logic required to perform all the various ICD-9 to ICD-10 mappings.  An alternative to consider may be to expose data as RDF triples in order to leverage a common logical model (every triple has a subject, predicate, object) which can facilitate more rapid federation and analysis of data across numerous heterogeneous data sources.  For example, relational data can be exposed as RDF using tools such as D2R which generates SQL and converts the data to RDF on the fly.   Messages encoded in XML can be converted to RDF using GRDDL.  RDF data is queried using SPARQL, and SPARQL can easily federate data from multiple SPARQL endpoints, RDF triplestores, or RDF files. As a SPARQL endpoint makes the data available over HTTP – it is much easier to establish connectivity to the various data sources.

A major roadblock to any kind of data integration or federation project is the varying nomenclature and semantics found in our systems.  Using semantic web standards – an ontology can be developed and used in order to help resolve these roadblocks at query time.  For example, if in one system the term “kidney failure” is used while in another the term “renal failure” is used – in our ontology we can state that these terms are synonymous (e.g., systema:kidneyFailure owl:sameAs systemb:renalFailure).  We can now find the data using the terminology we’re familiar with, regardless of nomenclature used in the different systems. 

While these technologies are relatively new – they are gaining in acceptance.  Case in point – ICD11 will be published in OWL (Web Ontology Language).  The Query Health initiative is looking to develop the Linked Health Data Cloud using semantic technologies. 

RDF follows a significantly different paradigm from the relational model.  SPARQL (the query language for RDF data) differs from SQL, and developing ontologies in RDF/RDFS/OWL and encoding business rules in SWRL will all require a learning curve. However, these technologies are being used today in the healthcare setting.   The Cleveland Clinic uses semantic technologies “to improve future patient care through outcomes-based and longitudinal clinical research”.  The Mayo Clinic is using these technologies for helping consumers find information without having to know all the underlying medical terminology with its Mayo Consumer Vocabularies initiative.  Wellpoint is looking to leverage IBM’s Watson (which leverages ontologies for question answering) in a clinical setting.   Providers and payers with mature and technologically savvy IT organizations might investigate leveraging semantic technologies to ease the transition to ICD-10.

Security and the Future of Healthcare

Poor IT security practices continue to plague the healthcare industry. Last year, a Ponemon Study found that poor security practices cost the healthcare industry $6 billion annually and that the HITECH Act has not resulted in changes to the approach taken to manage protected healthcare information. When an industry is under scrutiny for out-of-control escalating costs and the government has intervened with substantial amounts of incentive dollars to address issues, organizations must take a proactive approach to resolve issues.   

Of course, it can be difficult to not hone in on a specific goal, but this is not the time to take a “this-or-that” stance to meeting government mandates.  No organization can afford to focus on Meaningful Use and minimize efforts for the 4010/5010 conversion and ICD-10 implementation. The prudent thing to do is step-back and examine your options – take a “this-and-that” perspective to juggling the changes.

A “this-and-that” perspective is necessary because 4010/5010, ICD-10 and Meaningful Use are all connected and require security and privacy is maintained.  Since it is impossible to be in compliance with ICD-10 without having converted to 5010 transaction codes, organizations must fully embrace each of these building blocks.  

It is one of those rare cases where we can only speculate about the future changes that will spur from 4010/5010, ICD-10 and Meaningful Use, but we do know that security is not only a necessary component of the changes, but also a broadening area of focus that includes portals to securely communicate with patients, care for patients online, move information throughout an organization and ways to better embrace social media within healthcare

Portal enhancements are taking place within all areas of the healthcare industry. 


Don’t Drop the ICD-10 Ball in the Regulatory Deadline Juggle

We are at the AHIP Conference this week, which is one of our favorite events of the year.  It is good fun to meet with the many tech-savvy professionals that make up the health insurance industry.  This year we meet as many regulatory pressures and deadlines are closing in, which is certain to ignite some excellent conversations and knowledge sharing.

Leaders in the healthcare industry are juggling a series of regulatory deadlines and are struggling to keep up.  With 5010, ICD-10, ACO, HIPAA privacy updates, and Meaningful Use, many feel that there are just too many IT projects to keep straight.  With regard to ICD-10, and the prerequisite 5010 transaction set, survey after survey has shown that the healthcare industry is procrastinating.  This is not a surprise.  Fair or not, the healthcare industry has a reputation for procrastination.  One main reason for this procrastination is the hope that the government will blink and push back deadlines.  This game of chicken could prove very costly.

On the provider side, if organizations do not meet the October 1, 2013 deadline, then they will not be able to bill health plans for services.  These deadlines can represent a tremendous cost burden as a result.  If things continue at this rate, then health plans may start receiving claims in both ICD-9 and ICD-10.  Imagine the administrative burden of running two operating systems at the same time.  If they choose not to take on the burden of a dual system, these health plans will need to decide if a claim transmitted with the old ICD-9 code set will be rejected.  Doing work and not getting paid for it is the ultimate cost of procrastination.  Even a 1% decrease in revenues could prove disastrous.

Reward for the Pain of 5010 and ICD-10

Many feel that there are just too many IT projects on the table at once.  However, the transition to ICD-10, and the 5010 precursor, are not just IT projects.  These changes denote a transformation in the way of doing business in healthcare.  This is particularly true for health insurance plans.  This is because data integration is key to completing these conversions.  There are numerous siloed data systems across a healthcare organization in terms of clinical systems, claims, A/R, etc. which become integrated as a result of remediation.  This data integration in and of itself creates a bevy of “next generation” operational benefits, such as those experienced by BCBS of Massachusetts.  As highlighted in an earlier post, there is a reward for the pain of 5010 and ICD-10.  These rewards include:

  • A new level of transactional analysis by virtue of the expansion of the sheer number of new codes from ICD-9
  • The ability to generate more specific clinical data for quality metrics and tracking of resource use, which could save money
  • Improving the quality of operations and the level of understanding in a complex healthcare business, which can save time, money and maximize return in the long run for the U.S. healthcare delivery system
  • The ability to re-structure how a healthcare organization views its service lines for operations and profitability
  • Analysis, database remediation, database migration and testing brings a new detailed capability to examine the profitability and costs by procedure, the costs of specific diagnoses, and potential operational savings from best practice
  • Using re-worked analytic reports built around ICD-9 codes to examine the bigger picture of how business intelligence, decision support and analytics should perform
  • New opportunities for building more comprehensive data marts and stronger operational reporting including digital operations dashboards
  • For the more progressive IT teams, ICD-10 remediation could be an opportunity to move to a self-service model for reporting that capitalizes on a new generation of business intelligence tools

The best advice to healthcare organizations watching the ICD-10 time clock: Don’t treat ICD-10 as just another compliance issue.  Instead, use this as an opportunity to transform into a world-class healthcare organization.