While 5010 has taken a backseat to ICD-10 in the media, payers must still meet the change to 5010 on January 1, 2012 before implementing ICD-10. Version 5010 accommodates the ICD-10 code, and must be in place first before the changeover to ICD-10.
ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. Otherwise, claims and other transactions may be rejected, and will need to be resubmited with the ICD-10 codes. This could result in delays which would impact the timing of reimbursements.
The combined 5010 and ICD-10 changes will impact people, process and technology across the entire payer organization. Payers must assess which ICD-9 codes that will have the greatest volatility within a forward and backward crosswalk clinical equivalency map. The primary criteria for assessing code data impact will include frequency of code use and cost of associated benefits.
To put the change effort into context, the support associated to determining defensible medical policy, executing a forward crosswalk and validating the clinical equivalency map with a backward crosswalk for 155,000 combined diagnosis and procedure codes would take 155,000 hours at 1 hour per code. From today, there are only 110 weeks remaing till the ICD-10 compliance deadline of October 1, 2013. Based upon a 40 hour work week, it will take over 35 dedicated staff to just administer the clinical equivalency mapping of all codes.
Rumors persist that CMS (The Centers for Medicare and Medicaid Services) will again reset the ICD-10 compliance deadline, but don’t count on it. Implementation planning should be undertaken with the assumption that the Department of Health and Human Services (HHS) will NOT grant an extension beyond the October 1, 2013 compliance date. HHS has no plans to extend the compliance, which means that covered entities should plan to implement ICD-10 for production use on October 1, 2013.
Most payers will utilize the CMS Gerenal Equivalency Map (GEM) documents for ICD-9 Diagnosis and Procedure code mapping to ICD-10 codes which will support of the forward crosswalk but will not support the backward crosswalk necessary for financial and benefit neutrality verification. Payers will need a method and process of collecting the critical details that explain how and why the codes are related, or where they differ. Payers will have to spend a significant amount of time and effort to evaluate those differences.
Defensibility of code mapping will require a deeper understanding of historical ICD-9 coded claims data and corresponding ICD-10 code mapping. Analytics tool vendors are currently developing and refining their capability to support the automation of the historical claim data analysis to determine frequency of code use and cost of associated benefits. Payers understanding of which ICD-9 codes create revenue risk or associated benefit risk will enable the use of this analysis to prioritize and focus efforts to reduce mapping volitility.
Automating code mapping analysis will reduce the time and resources needed for developing defensible code mapping for individual codes based on frequency of code use and cost of associated benefits.
Do you have questions about ICD-10? Join me on September 15th for a free webinar “Opportunities Abound: Leveraging the Increased Data Granularity in the ICD-10 Code Set”. Register today
