ICD-10 Transition for Payers

Beginning Oct. 1, 2015, the U.S. government is mandating the shift from the existing ICD-9 code system to ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) — a coding standard already in use in many other developed countries around the world. The change will expand the number of codes to more than 155,000 from 20,000. In other words, healthcare providers will have nearly eight times as many codes to choose from to enter into a patient's medical record to describe why the patient sought care and how that patient was treated. The differential between the number of ICD-9 and ICD-10 codes will mean that, in many instances, no "crosswalks" will exist for a one-to-one code match.

The ICD-10 changes come at a time that payers also need to be concerned about the extensive changes emanating from the Patient Protection and Affordable Care Act.

As a payer, mapping of code sets is merely your first step in the transition process from ICD-9 to ICD-10. Your long-term success is reliant upon having a robust and clinically sound medical policy to handle the expanded clinical detail inherent in ICD-10. The changes will drive updates to the information systems related to contracting, eligibility and benefit determination; reimbursement policy; notifications such as Explanation of Benefit/Evidence of Coverage (EOBs/EOCs); utilization reviews; fraud and abuse detection; claim adjudication and claim code edits; statistical analysis; and pricing and data abstracts.

The changes will require:

  • Reviewing all systems that use an ICD-9 code
  • Reviewing and addressing medical policy including InterQual® readiness  
  • Having the ability to support both ICD-9 and ICD-10 codes for a transition period
  • Evaluating the need for additional staff to handle customer service demands and increased denials during code set cut over 

Health and Human Services notes that the benefits of ICD-10-CM and PCS will start to appear the year after the code set has been implemented. The benefits include the following:

  • New and more complex procedures will likely be assigned codes that accurately describe the procedure, in contrast to the current system where new procedures are often inappropriately grouped, which may lead to inaccurate payment
  • The specificity and detail in ICD-10-PCS will reduce the need for claim attachments and the number of claims that are rejected due to the lack of information needed for adjudication
  • The specificity of ICD-10 is expected to reduce the number of miscoded claims that result from the ambiguity of the ICD-9 codes
  • The specificity will allow more comprehensive quality reporting and improve disease management

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