January 15, 2013

Code Set Competency: Six Steps to a Successful Transition to ICD-10 - Pt. 2

By Carol Spencer and Mike Younkman

EDITOR’S NOTE: This is the final installment in a two-part series

To be successful using ICD-10, payers, providers and vendors should follow six simple steps for management of code transition from ICD-9. It is critical that each organization apply a common mapping consistently in order to meet the compliance date.

Industry goals include compliance and business neutrality, as well as more accurate and detailed clinical and quality reporting, improvements to patient safety, better tracking of patient outcomes, improvements to the accuracy of claims processing, prevention of fraud and abuse, and the availability of richer sources of data for clinical research.

Here are the last three of those aforementioned six steps:

1. Quantify cost of care and administrative costs related to the ICD-10 transition.
For WellPoint, code set translation expertise has helped our enterprise identify more than 20 derivations totaling $300 million in paid claims with the potential for incorrect processing – a if the derivation was not modified in the WRM first. All organizations should analyze the impact of code mapping and translation on their financial health. It will allow your organization to begin to predict cost of care and administrative costs associated with ICD-10 implementation.

2. Use data analysis to identify maps that will need to meet your business rule.
After the tedious remediation work – reviewing rule-by-rule, code-by-code – we reach a baseline at which to jump-start our remediation efforts with the four remaining smaller platforms.

Because of the work completed on the two large platforms in 2012, efforts that determined that only 5 percent of the mappings were not accepted, leverage was lent toward our 2013 work effort. We plan to start working with the remaining four platforms at a higher level, namely by conducting data analysis of the business rules.

First, we will compare the rules to the Business Configuration Inventory to determine acceptance of these derivations among the four platforms being remediated in 2013; second, we will analyze for aberrancies in codes that are of high impact related to the known ICD-10 changes and their impact to the business rule. We will be able to work smarter, not harder, in 2013.

3. Instill committee oversight to analyze for purpose-built maps (PBMs).
To manage and track mapping and translation decisions, all organizations that use ICD codes should establish an ICD-10 decisions and controls committee.

This committee’s core responsibility is to review derivations from the WRM to determine if the entire organization can take advantage of these derivations. All derivations should be reviewed by all business stakeholders. If approved, each derivation is implemented into the enterprise reference map as a purpose-built map (PBM). For example, the subsequent encounter codes (ICD-10, S and T codes with a seventh digit of D, or “fracture”) were added to the initial encounter code maps. There were numerous business reasons for this decision, one being a high error rate for coding of the initial injury rather than the aftercare code in ICD-9 (particularly in the non-acute setting).

Healthcare industry stakeholders should view consistent and predictable cost of care, continuation of stable administrative costs, and accuracy of translation to be the primary goals of ICD-10 remediation work.

Following the key steps outlined above, in addition to those described in part one of this series, will help focus your organization’s efforts on areas that will support these key goals.

About the Authors

Carol Spencer is the program director for WellPoint’s CodeSet Competency Center. Mike Younkman is the director of WellPoint’s ICD-10 execution.

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Click here to read Part 1 of this series