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Claims and Coding: Roundup Key is remediation

Ray Desrochers, COO, HealthEdge

As we move from the 17,000 ICD- 9 diagnosis and procedure codes to the 155,000+ ICD-10 codes, every system that uses these codes will need to be remediated. Similar to the challenges that organizations faced when addressing Y2K, the longer ICD-10 codes will require, in many cases, signifi cant database changes, data migrations and modifications to numerous interfaces that are used to move data between various internal and external systems.

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To help reduce claim and coding errors and ensure a smooth migration to the new standard, payers should employ the following strategies when transitioning to ICD-10:

• Start by training key business users and technical staff so they understand the differences between ICD-9 and ICD-10. This will allow people to be more proactive and make better decisions and recommendations related to both system remediation and how the organization can best leverage the new codes.

• Put a staged remediation plan in place that will allow the organization to design, build, test and roll out smaller changes over time, rather than address the entire effort all at once. This will help to ensure a more orderly transition to ICD-10, and it will help to avoid business and resource collisions.

• Evaluate all of the interfaces that exist between internal and external systems, healthcare data exchanges and partner networks. People often forget these during remediation planning, and are surprised by them later.

With a little planning, payers can enjoy the signifi cant

benefi ts of ICD-10 and ensure a smooth transition to this important new standard.

Mobile solutions are important

Today’s healthcare organizations are increasingly turning to the use of mobile solutions in their transition to ICD-10, particularly those built o

a o t

on coding expertise. Healthcare o

organizations can use mobile d

Paul Adkison, CEO and founder, IQMax

12 July 2011

devices to help reduce claims and c

coding errors by implementing frf equent charge sets for services rendered throughout healthcare facilities in a way that empowersf care providers to capture and

deliver valid ICD-10 charges from their mobile device of choice. The same content and coding knowledge leveraged for frequent charge sets can also be utilized to create ICD-10 charges from dictations captured during the patient encounter in a mobile environment. From these mobile solutions, healthcare organizations can more easily transition to ICD-10 by submitting complete and valid charge claims that originate from the point of care. All of this is accomplished without the need for physicians to be trained on the intricate details and magnitude of newly created charge codes that will be forthcoming with ICD-10.


Must have detailed contracting arrangements

ICD-10 will have a signifi cant impact across the payer

and provider food chain, not only limited to direct impact points, such as revenue cycle management (RCM), but also business areas, such as medical policy management, benefi t design and provider contracting. The most important requirement for reduction and elimination of coding and claim processing errors is for payers and providers to have established detailed contracting arrangements for each single diagnosis- related grouping (DRG) corresponding to new ICD-10 codes. It is a task easier said than done and will require some prior research by both sides to fi gure out the impact. Payers are already working on analyzing their historical claims to fi gure out the high-value payout categories. It is absolutely essential for payers to use some kind of a modeling tool that leverages the historical claims data to predict the impact on payouts with ICD-10. Some of the models available in the market are sophisticated enough to allow multiple types of slicing and dicing of data against a variety of DRG-ICD combinations to throw out invalid combinations, establish primary and secondary code dependencies, and allow end users to create trial scenarios to test out their baseline assumptions. The actuarial staff can also use these modeling tools to establish new benefi t design guidelines for the ICD-10 world. Providers must also use similar kinds of modeling tools to establish the proper reimbursement rates for each new code. Once both sides are done with proper models, based on their high-value payouts (in the case of payers) and areas of specialty (in case of the providers), it will behoove both parties to establish new contracts lest there be any confusion regarding the amounts being paid out. The establishing of these new contracts will go a long way towards future reduction of coding and processing errors.

By Rajiv Sabharwal, chief solutions architect, healthcare and life sciences, Infosys Technologies

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