Compliance with ICD-10 demands a significant effort spanning many parts of healthcare organizations. According to WEDI, “ICD-10 is expected to be the most costly government-mandated change ever to hit the healthcare industry.” (1)
The scope of this transition is daunting. While ICD-9 contains 14,000 diagnosis codes, ICD-10 has nearly 70,000; likewise, ICD-9 has 3,800 procedure codes compared to 72,000 in ICD-10. Unlike the conversion to HIPAA 5010, which involved primarily IT systems and application, ICD-10 will affect both IT and many operational areas. A significant component of ensuring compliance with ICD-10 involves assessing the readiness of business partners to work with the new ICD-10 codes.
As with any new mandate, there currently is limited knowledge about how to proceed. One of the ways your organization can address this is to review the various best practices models available from CMS, AHIMA and WEDI, among other organizations. This will give your organization a way to evaluate how your efforts compare, what steps you should be taking and when you should reach certain milestones.
Because the use of ICD-9 codes is so pervasive inside payer and provider organizations, the transition to ICD-10 will impact organizations even more broadly than the 5010 transition. ICD-10 conversions will have to include test results, documentation, policies, guidelines, and other efforts that will drive the enormous amount of communication that will need to occur between trading partners. As a result, your organization may have to expend tremendous energy to assess and manage vendors, affiliates and trading partners.
Affiliate readiness is one area in which healthcare plans and healthcare providers have different yet parallel needs. For both, communication and coordination with trading partners and affiliates is critical. However, the terms “trading partners” and “affiliates” are used somewhat interchangeably. Fundamentally, every healthcare organization needs to work with three distinct groups:
Vendors: IT vendors are clearly primed to be involved with the early part of the critical path to move forward with the ICD-10 transition. Payers and providers have very similar needs in assessing vendor readiness, tracking commitments and understanding risks.
Service providers: Just about every organization outsources many functions today. Service providers may take your data and run it on their systems, or they may access your systems directly. As with vendors, payer and provider needs are the same for this group of trading partners.
Affiliates: Payers focus on those organizations that submit claims to them; typically these include clearinghouses and healthcare providers. With 5010, it may be necessary to test only with those who submit claims directly, as you are testing the ability to perform a relevant electronic transaction. With ICD-10, testing will be broader. Since the content of the transaction is critical, it will be necessary for payers to test with those who create the original claims or other transactions, and this is a much larger group. Providers must be concerned with the affiliates who determine the content of claims, such as your physicians, coders and other professional staff. These may be employees or outside affiliates such as physicians with privileges.
Large healthcare payer organizations may have thousands of vendors and trading partners, while large provider organizations easily can have hundreds. The best-prepared healthcare organizations are those that actively are assessing and interacting with their affiliates to ensure readiness.
About the Author
Hugh Kelly is the Vice President of Marketing and Sales for Avior Computing. Mr. Kelly has more than 20 years in the software and technology business at organizations ranging from start-ups to publicly traded companies. Mr. Kelly has been involved in all aspects of marketing and sales, with considerable focus on channel development. During his executive tenure, his organizations have raised over $200M in external capital. He is a venture partner at Ascent Ventures.
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(1) WEDI White Paper, ICD-10 Implementation