ICD-10: Lessons from Real-World Assessments
Healthcare payers can speed up ICD-10 implementation and move beyond compliance to use ICD-10 as a source of competitive advantage.
Version 10 of the ICD (International Classification of Diseases) contains more detailed information than ever before about the drivers and costs of medical care. In customer engagements, Cognizant has identified ways that payers can speed ICD-10 implementations and move beyond mere compliance to using ICD-10 for competitive advantage.
Think Through the Transition Carefully
We've found that ICD-10 implementation requires much more than simply layering ICD-10 codes over existing systems. Doing so risks expensive inefficiencies, such as revamping just-finished workflows and database tables to reflect ICD-10-based policies. Finding such potential problems requires payers to look beyond current business processes and models. Many payers hope to use the new level of detail offered by ICD-10 to identify at-risk populations, detect fraud and abuse and enable new types of care and reimbursement models. But because most of these new programs are still small, it is not yet clear how much they will rely on ICD-10 codes. Remember also that ICD-10 codes may be used in ways that ICD-9 codes can't be. In at least one case, the scope of remediation is so great that a payer is selling a business whose returns don't justify the expense. Look ahead to how ICD-10 will change your business and build these projections into your migration plans.
Watch the Schedule Impact
You may need to speed or delay new initiatives or systems deployment depending on how soon their capabilities will require ICD-10, or how soon the applications will support ICD-10. For example, some payers may delay scaling initiatives such as Patient Centered Medical Homes and Accountable Health Organizations until they have implemented the ICD-10 codes they require.
Consider a Staggered Deployment
Some payers plan to run native ICD-10 by October 2013, hoping to be among the first to launch new delivery models, intervene in existing populations with better data and identify populations more effectively. But until the industry learns ICD-10, payers will receive many incorrect codes from an inexperienced provider community, introducing costly errors and rework. Until ICD-10 code use matures and generates credible data (not before late 2014) consider protecting some systems behind crosswalks, migrating only systems that produce the greatest short-term benefit while industry adoption matures.
Search Carefully for ICD-10 Impacts
Because codes are so embedded within complex applications and processes, it's difficult to predict where they will need to be adapted. For example, ICD-9 codes are broad and less specific than those in ICD-10. That means they are not always as deeply embedded in expected areas, such as physician reimbursement rates, as ICD-10 codes will be. On the other hand, ICD-9 codes are central to benefit definitions and parameters, forcing payers to do extensive remediation in these areas. Be flexible in reallocating budget and time as you learn more about the actual effects of ICD-10.
Neither General Equivalence Mapping nor Crosswalks are a Silver Bullet
General Equivalence Mappings (GEMs) from the Centers for Medicare and Medicaid Services include all reasonable mappings of ICD-9 to ICD-10 codes. However, many ICD-9 codes do not map directly to ICD-10, and it is not always advisable or possible to simply substitute one for the other. Payers must map these outliers properly to ensure they have no financial impact on policyholders or providers. This means mapping ICD-10 codes to Diagnosis-Related Groups (DRGs), which is emerging as the area of greatest remediation complexity.
Many payers see the need for "forward" crosswalks so that they can map an ICD-9 coded claim from a provider to ICD-10. But these crosswalks will require significant modeling and testing to ensure they do not affect policy holders' reimbursement and benefits. Moreover, payers are discovering they can't crosswalk between old and new codes as transactions move among systems to the degree they expected. Although adjudication rules are relatively easy to handle via crosswalks, authorizations, referrals, hospital payment rules and analytics for care management should be ICD-10 from day one.
Coordinate Your Plans With Your Business Partners
Successful adoption of ICD-10 codes involves not only internal processes and systems but physicians, hospital systems and technology vendors. On the provider side, high-risk areas we've seen include medical management (due to the number of codes and narratives involved) and utilization management, because of the potential for clinical decision and claims reimbursement errors. On the systems side, many software vendors have yet to announce timetables for ICD-10 compliance, and we expect many to only provide field expansions, leaving the definition and configuration of rules to payers.
Get more insights from our Healthcare Practice or read the complete white paper: ICD-10 - Early Lessons from Real World Assessments