Avoid Getting Burned on Your ICD-10 Transition

On October 1, 2014, the 30 year old ICD-9 code sets used to report medical diagnosis and inpatient procedures will be replaced by a new ICD-10 code set. So if you’re ever burned due to your water skis being on fire, we’ve got a code for you. Seriously. It’s ICD-10 code-V9107XA.

If you are involved in health care, chances are you have heard about the ICD-10 transition. This change affects clinics, facilities, health plans, and anyone covered by the Health Insurance Portability Accountability Act (HIPAA). The transition to ICD-10 is occurring because ICD-9 produces limited data about patient’s medical conditions and hospital inpatient procedures. ICD-9 uses outdated terms and is inconsistent with current medical practice. In addition, the structure of ICD-9 limits the number of new codes that can be created and many ICD-9 categories are full.

How Health Plans Can Prepare

Even if you’re not already in the middle of an ICD-10 implementation, there are a few things you can be doing now to get ready for the October 14 deadline:

  • Identify current system touch points and work processes that use ICD-9 codes.
  • Talk with vendors about accommodations for ICD-10 codes.
  • Review contracts for ICD-10 implementation changes.
  • Identify potential work flow changes and training needs.
  • Understand the potential DRG shift changes.
  • Conduct extensive testing with providers as testing partners.

You should also note that not every Health Plan will begin accepting ICD-10 codes at the same time. Some Health Plans will accept them as early as January 2014 (for services after 9-30-14) while others will not accept any ICD-10 codes until October 1, 2014. This may cause confusion with providers trying to get prior authorizations that span the transition date. Therefore, it is imperative that communication with providers and vendors start early and remain constant regardless of the date your Health Plan has chosen to accept ICD-10 codes.

Prior authorizations Issues

If your health plan receives prior authorization requests that span a year or longer, be sure to think through how you may need to limit your system. Most health plans will receive authorization requests in which the date of service is beyond the 9-30-14 cut-off date for ICD-9 codes long before the system is ready to accept ICD-10 codes. A system limit may be needed because letters are not ready or the system configuration is not complete. And remember, most providers are not equipped to give ICD-10 codes because they, too, are working on being compliant. Here are some things you should consider:

  • When you decide on a go-live date, are you contractually obligated to give your providers a specific amount of notice that a process will change?
  • How long will it take to get the communication finalized and what routes will you use to notify the providers of changes?
  • If you set a system limit that does not allow ICD-10 until a later date, how do you handle authorization requests coming in, today, that span the transition date of 9-30-14?
  • If you currently set a system limit that allows ICD-9 through the transition date because the system and the providers are not ready for ICD-10, but your authorization request are for a year or longer, how do you resolve those authorizations when the system can handle the ICD-10 codes?
  • If you set a system limit that does not allow ICD-9 codes after 9-30-14 how do you handle the authorizations currently being received that span the transition date?

Take a deep breath

When you have completed your transition, you may feel like you have been bitten by an Orca, initial encounter (ICD-10 code-W5621XA), struck by a macaw (ICD-10 code-W6112XA), or even hurt walking into a lamppost (ICD-10 code-W2202XA) but you will have the satisfaction of a job well done. Optimization is key.

Author: Maryann Jaros, LPN, is a Facets Consultant with 25+ years of healthcare experience. She is an expert in Health Plan clinical configuration, testing and training of Business Processes and Informatics. She has vast experience around UM and CM as well as HEDIS collection and reporting, and more.