ICD-10 Compliance

On January 16, 2009 the Department of Health & Human Services (HHS) published two final rules (45 CFR Parts 160 and 162) mandating the adoption of updated HIPAA standards. The Centers for Medicare and Medicaid Services (CMS) is responsible for oversight of compliance with the standards.

The first rule requires updating version 004010 HIPAA transactions (commonly referred to as 4010 and 4010A1) with the new 005010 (5010) transactions by January, 2012. The second rule requires adoption of ICD-10-CM and ICD-10-PCS code sets, replacing ICD-9-CM, by October, 2013. Implementation of ICD-10 cannot occur prior to implementation of HIPAA 5010 transactions.

Background

ICD 9-CM codes were developed in the 1970’s and have been is use for over 30 years. ICD-9 codes are used for numerous business functions such as claims processing, remittance, advice, eligibility inquiries and referral authorizations.

Because ICD-9 is dated and the current procedure and diagnosis codes are insufficient to allow for new codes to reflect current medical practice, ICD-9 has become obsolete. Other key drivers for the use of ICD-10 include ICD-10 now being the international standard for reporting and surveillance of diseases and mortality and the use of ICD-10 to facilitate health information technology (HIT) standardization.

Key ICD-10 Challenges

The complexity and scope of ICD-10 will create a number of sweeping challenges within the U.S. healthcare system such as:

• ICD-9 contains around 17,000 codes, ICD-10 contains more than 150,000 codes
• ICD-10 will require several codes to cross-walk to a single ICD-9 code
• ICD-9 to ICD-10 code mapping will require detailed translations in benefit plan configuration and claims adjudication logic
• Remediation of ICD-10 will require extensive technology modifications to databases, reports, computing logic, data imports and extracts, business desktop and workflow procedures, etc.
• The need to process both ICD-9 and ICD-10 codes for a period of time and normalize the data for comparability and trending
• Inaccurate processing and reporting of ICD-9 and ICD-10 codes coexisting in a single database
• Operational productivity loss across the organization
• Extensive training across many cross-operational departments
• Claims backlogs and payment delays due to coding and reimbursement discrepancies
• Impact on historical data used for underwriting and rating due to use of old ICD-9 codes and new ICD-10 codes
• Potential increase in fraud and abuse
• The need to remediate multiple core claims platforms (if applicable)
• The need to replace obsolete legacy/proprietary or packaged applications that will be difficult or very costly to remediate to achieve ICD-10 compliance
• Implementation costs are estimated to rival or exceed the costs of Y2K and initial HIPAA implementations
• Staffing shortages, especially in IT

What the ICD-10 Transition Means to Your Organization

Estimated Costs & Benefits – The estimated costs of ICD-10 compliance industry-wide vary significantly but are expected to be significant. We will help you estimate the costs of your ICD-10 compliance initiative so your organization can plan and budget properly. Our team can also help you identify, plan and realize the benefits associated with ICD-10.

Complexity & Risks – Our experienced business and information technology consultants can help you manage the complexity and risks associated with implementing ICD-10. Some of these risks include inability to accurately process, pay, submit or accept claims, disruptions to operations, cash flow and revenue, strained relationships with your members, providers, brokers and business partners and increased fraud, waste and abuse.

Business and Operational Impact – The business and operational impact of ICD-10 will be significant. We help you analyze a variety of key business issues such as plan products, benefits, contracts, billing, claims processing and medical management and determine the risk, impact and solutions in each area.

Systems Modernization or Replacement and Vendor Relationships – eHealthPartners team is highly qualified to help you determine how and when your software vendors will provide ICD-10 solutions, determine any remaining gaps in those solutions, determine if systems or technologies need to be replaced and determine how your business partners systems and compliance solutions will affect your organization.

Staffing, Training & Change Management – Due to the volume of work associated with ICD-10 compliance, eHealthPartners will help you identify additional resources needed to support ICD-10 efforts, redeploy current staff and identify external consulting requirements. We will also help you develop adequate ICD-10 training programs and a change management and communication plan necessary to effectively manage the change process and keep your employees informed.

Our Approach to ICD-10 Compliance

eHealthPartners has developed a structured compliance methodology to help lead, guide and assist your remediation teams through the entire ICD-10 remediation effort.

Major phases of our ICD-10 Compliance solution include:

    Phase 1 – ICD-10 Awareness & Readiness Assessment
    Phase 2 - Establish Governance
    Phase 3 - Remediation
    Phase 4 - Testing & Training
    Phase 5 - Transition

eHealthPartners ICD-10 Services

eHealthPartners provides a broad base of ICD-10 compliance related services including:

• ICD-10 Executive Education
• ICD-10 Awareness & Readiness Assessment
• ICD-10 Compliance Strategy Development and Program/Project Planning
• Program & Project Management including Governance Structures and Processes
• Business Analysis and Process Redesign
• Remediation
  • Business Processes (Configuration, Claims, Workflow, Medical Management)
  • ICD-9 to ICD-10 Crosswalks
  • Configuration / Business Rules
  • Benefits & Pricing
  • Provider Contracting
  • Claim System/Application/Database Upgrades
  • Interface Remediation
  • Database / Reporting Impacts
  • Third-Party Ancillary Application Upgrades
  • System Integration, Development and Code Remediation
  • HIPAA Transaction/EDI Implementation
• ICD-10 Related QA and Testing
• ICD-10 User Training

Our team includes a broad range of health insurance consultants who will help your organization successfully implement ICD-10 such as Business and IT strategy consultants, Program/Project Managers, Business Analysts and Process Redesign consultants, Configuration consultants, Technology consultants, Developers, Database consultants, Testing consultants, Clinical consultants, HIPAA/EDI consultants and Trainers.

Successfully achieving ICD-10 compliance will be a complex, time consuming and potentially costly process. Organizations who delay taking action will most likely find themselves without sufficient time to implement efficient and cost effective ICD-10 solutions.

The first step is conducting an ICD-10 Awareness and Readiness Assessment.

Get started today by contacting us to discuss how we can assist your organization with successfully achieving ICD-10 compliance.

To learn more about our services please call us at (678) 387-6330 or email us at sales@ehealthpartners.com