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 Thought Leaders

Paradigm shift

How ICD-10 will change healthcare.

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   By Dean Boyer, September 2013

There are those professionals in healthcare today who see the transition to ICD-10 as an uncontrollable juggernaut that is going to overwhelm their very existence. 

Like it or not, when the compliance date is reached on Oct. 1, 2014, providers, hospitals and insurance companies must have the ability to send and receive claims in ICD-10. In preparation for the transition, physicians, medical coders, health information management (HIM) professionals and payers have begun the arduous task of learning ICD-10. Software vendors such as 3M, Epic, Cerner and HRAA are working with their clients to ensure they support the transition process. Unfortunately, all of this activity is focused on the transition, rather than the impending paradigm shift that will impact the way healthcare has previously been delivered.

By the numbers

CMS has provided maps to help understand how the ICD-9 codes relate to the ICD-10 codes, which account for all 18,445 ICD-9 codes, of which 635 of the codes were not mapped to any ICD-10 codes. This means CMS mapped 17,810 ICD-9 codes to 62,832 ICD-10 codes, which means 78,920 of the ICD-10 codes were not mapped.

When we begin to study the taxonomy of the codes based on these numbers, a shift in our value system takes shape.

The taxonomy of ICD-10

A basic premise made about the transition to ICD-10 is that it provides greater specificity. The numbers would imply this to be true, until you question why CMS did not map 78,920 ICD-10 codes, of which 53,227 are diagnosis codes and 25,693 are procedure codes. Further examination of the data reveals that not all codes provide a more specific view of data. 

This illustrates that the basic premise – that ICD-10 codes are a further classification of ICD-9 codes – is flawed. They do provide for a more granular representation of the services provided to a patient, but that does not always correlate back to the application of the ICD-9 code. Understanding these dynamics will help healthcare systems prioritize their training. 

Preparing for ICD-10 goes beyond just learning the codes; it will require understanding practical implementation that can only be achieved through practice and dual-coding efforts.

Changing the
healthcare value system

ICD-10 will change the way we perceive healthcare.

Today, everything is about learning the ICD-10 codes, but as time wears on, both hospital and insurance administrators will begin to understand the full impact of these codes. Performance and quality metrics will need to be evaluated for their derived benefits and accuracy. One ICD-9 code describing an individual receiving a pacemaker now requires four ICD-10 codes, so how does this fit into an existing algorithm measuring the successful treatment of heart patients? This type of question needs to be answered in the upcoming year if hospitals and insurance companies are going to be able to successfully report and analyze their operations with their current set of tools.

Then there is the issue of hospitals learning to code with 141,752 ICD-10 codes, and payers only mapping a subset of those codes. If insurance companies don’t update their adjudication systems and plans with all ICD-10 codes, how will hospitals know which codes are in use and which are not? The lack of communication between hospitals and payers, absence of utilization standards and total shortage in experience with ICD-10 codes could be a recipe for disaster. If a payer denies 35 percent of hospital claims, will that be enough to create cash-flow deficits, which may result in hospital closures?

Even if a hospital gets ahead of the curve and is ready to start testing its ICD-10-based claims, are the insurance companies ready to switch over their adjudication systems to accept claims based on ICD-10 codes? The list of questions goes on. Hospitals and insurance administrators need to start testing now if they are to survive this pending paradigm shift.

Until proper testing has begun and/or the transition takes effect, healthcare systems will need to be nimble and ready for anything. 

As a country, we put what seemed like endless resources into our preparations for Y2K. Now healthcare is faced with an even bigger challenge, and it seems as though the issues have been lost in the world of medical coding and HIM. Granted, those hospitals that are already engaged in training for the ICD-10 transition will be prepared. Unfortunately, it is the rest of the healthcare ecosystem that is at risk.

About the author

Dean Boyer is CTO, Health Revenue Assurance Holdings. For more on HRAA, click here.


Tags:  ICD-10