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• Increased ability to measure performance and to provide offerings based on service excellence
• Improved quality of care and patient safety due to better data
• Less ambiguity in the code set provides a potential for reduction in coding error rates that lead to rejected claims

• Staffing challenges–Industry estimates tell us that experienced coders and IS staff with knowledge of key systems will be in high demand. Currently, the market is already in short supply for these resources, and demand for these skills is expected to peak in the period before and after transition.
• Productivity decreases–Based on the transition to ICD-10 in other countries, the additional complexity and detailed nature of the classification system will decrease productivity. Even after the learning curve, it is expected that the productivity related to coding activities will not return to pre-ICD-10 levels.
• Increases in claims rejections–It is projected that there will be an increase in claims rejections during the immediate period following transition. This is attributed to lack of familiarity with coding specifics and the requirements for more detailed documentation.
• Training activities-Your organization’s training effort will need to have a broad footprint. Different levels of training will be appropriate across most of the enterprise with coders, physicians, clinicians and support staff requiring awareness of the changes to business processes and standards. In addition, there may be other support activities, including standard updates and audits to help reinforce new standards to ensure successful transition to ICD-10.

4. What steps can I take now to get my organization started on the path to ICD-10 compliance?

There are several recommended steps; a few are suggested below:

• Identify all systems and processes, electronic as well as manual, in which ICD-9 is used. These will include HIS and practice management systems, clinical documentation, EHR systems and quality reporting.
• Approach software vendors about their plans to address the transition and about their timelines for upgrading their software. Keep in mind that certain upgrades will be covered in annual maintenance contracts.
• Likewise, talk to clearinghouses, billing services and payers about when they will be upgrading. Also ask if implementing ICD-10 codes will require changes to contracts.
• Establish an ICD-10 steering committee, with at least one C-level executive as a member that will assess the business processes, clinical workflows and IT systems affected by the conversion.
• Pinpoint staff training needs. This includes obtaining materials, establishing a timeline and choosing a training format.
• Assess ICD-10 readiness, and assess the financial impact of ICD-10 on reimbursement processes.
• Draft an ICD-10 implementation budget. This should include system changes, business process changes, resource materials and training.
• Implement a remediation roadmap, with changes and other new processes continually evaluated along the way.
• Ask payers, clearinghouses and other partners to conduct a test to make sure they can, in fact, accept ICD-10 codes. Try to test each transaction that involves the swapping of ICD-10 codes.

5. What are the consequences of non-compliance with HIPAA 5010 and ICD-10?

• Reimbursement - The most significant negative impact will occur with reimbursement. If claims are not properly formatted to the new requirements, claims may be significantly delayed, or your organization may not be paid.
• Fines - No official word has been handed down regarding exactly what fines the federal government may levy against healthcare organizations that fail to comply with HIPAA 5010 or ICD-10, but there are industry discussions taking place on this subject.
• Long-Term Benefits - The failure to comply leaves your organization at risk for not achieving the full benefit of ICD-10, including better patient care and the ability to exchange data between entities. When healthcare organizations world-wide are using the same code set, experts suggest a rise in global healthcare quality.

• Field size expansion
• Alphanumeric composition
• Use of decimals
• Redefinition of code values
• Longer code descriptions
• Edit and logic changes
• Modification of table structures
• Expansion of some flat files that contain diagnosis and procedures codes

• will NOT change internal interfaces and custom reports.
• might not be timely. If timely, their timing might not synchronize with your timing.
• might not be fully compliant or fail compliance.
• might not decide to comply. If they do decide to comply, their compliance strategy might be different from your strategy.
• might not view their role the same as you do.
• might not be aware of your organization’s stand-alone applications or databases that utilize ICD codes.
• will NOT be accountable for examining and updating workflows, health plans, and business processes not contained in information systems.

3. Why do I hear HIPAA 5010 associated with ICD-10 so much?

In the simplest terms, organizations using electronic billing must convert to HIPAA 5010 standards in order to accept ICD-10 codes in electronic format. Therefore, HIPAA 5010 conversion with a federally-mandated compliance date of January 1, 2012, must occur before successful ICD-10 implementation. HIPAA 5010 is the updated version of the HIPAA electronic transaction standards and sets the stage for ICD-10 increasing the ICD code field size from 5 to 7 bytes and increasing the number of diagnosis and procedure codes allowed on a claim.

4. Why can’t we just use General Equivalence Mappings (GEMs) to crosswalk the information from ICD-9-CM to ICD-10-CM/PCS?

The General Equivalence Mappings (GEMs) are not a one-to-one match in many instances. These bi-directional maps were intended to assist the user in comparison of large, historical ICD-9 data sets to ICD-10. For the most accurate code assignment, ICD-10 and its Official Guidelines must be applied. Crosswalks may be a part of the solution, but they will not enable use of the greater information contained in the ICD-10 codes.

HIPPA 5010 & ICD-10 FAQ's "Payor Focus" for C-Suite at Healthcare Payor Organizations:

1. What is ICD-10?

ICD-10 stands for the World Health Organization’s (WHO) International Classification of Diseases, 10th edition. In the United States, ICD-10-CM and ICD-10-PCS will replace the current ICD-9-CM code sets used to report healthcare diagnoses and procedures. The new ICD-10 code sets incorporate much greater specificity and clinical information and are more consistent with today’s practice. The number of diagnosis codes will increase from approximately 13,000 current ICD-9-CM diagnosis codes to about 68,000 ICD-10-CM codes. The number of procedure codes will increase from approximately 4,000 current ICD-9-CM procedure codes in use to about 87,000 ICD-10-PCS codes.

2. Why is ICD-10 such a big deal? Is it hype or truth?

Practically all major areas within a payor organization will be affected by the adoption of the ICD-10 Codes. Business areas will be required to re-evaluate their existing policies, procedures, and processes. For example, claims business processes and systems are highly dependent upon medical codes for processing. Codes are used to determine whether services are covered, for benefit accumulation, and trigger logic within payor systems. Likewise, Provider contracting and communications with providers and other constituencies will be a significant effort. When all of that effort and the IT work is done, everything will have to be tested both internally and with trading partners to make sure it all works as intended.

3. Are other nations using ICD-10-CM and ICD-10-PCS?

Other nations use code sets that follow the World Health Organization’s (WHO) ICD-10 model, but have adopted their own enhanced version of the code set such as ICD-10-CA in Canada and ICD-10-AM in Australia. Similarly, the U.S. created a clinical modification (CM) to the ICD-10 diagnosis code set which is different from other countries’.

4. What are some of the key differences between ICD-9 and 10?

The format and length of these codes will change.

• Diagnosis codes will change from the current three to five, mostly numeric codes to three to seven, alphanumeric codes.
• Procedure codes will change from the current three or four position numeric code to a seven position alphanumeric code. Some sections have been reorganized.
  The number of diagnosis codes will increase from approximately 13,000 current ICD-9-CM diagnosis codes to about 68,000 ICD-10-CM codes. The number of procedure codes will increase from approximately 4,000 current ICD-9-CM procedure codes in use to about 87,000 ICD-10-PCS code

5. Is the Oct 1, 2013 compliance date for ICD-10 realistic? History suggests that CMS may delay the compliance date.

Based on all the indications, it seems that CMS intends to be ready to accept ICD-10 codes as of 10/1/13 and will not delay the compliance date. Because the final rule has been posted, and CMS has also invested in the systems and process changes as well as the planning required to meet the compliance date, it would be prudent to prepare now.

6. Is ICD-10 just a Systems / Technical issue?

No. The move to ICD-10 also constitutes a major impact to business. Every policy, procedure, contract, and other business object currently affected by the use of ICD-9-CM codes must be reviewed. The ICD-10 code set will need to be examined concerning business functions to determine if different actions need to be taken due to the new granularity and redefinition of diagnosis and inpatient procedure codes. Treatment and care management policies may need to change as well as a host of other functions. Organizations will need to examine every area where they handle or use a diagnosis or procedure code or their derivatives to determine potential business and system application impacts.

7. Are the CPT-4 and HCPCS codes impacted by this transition?

No. CPT-4 and HCPCS are not impacted and will continue to be used in its current form.

8. Since ICD-10 primarily impacts the medical codes, shouldn’t this only concern the clinical folks in my organization?

No. While the clinical area will be a major stakeholder in the transition to ICD-10, they will not be the only area which will need to be trained. Because the ICD-10 codes are so much more specific, many area such as payment, coverage, fraud and abuse, and actuarial will be impacted. All these areas need awareness, training, and education.

9. Can I wait until 5010 is implemented before addressing ICD-10?

5010 is a pre-requisite to ICD-10. With the new compliance dates in the final rules, it may be tempting to feel that the pressure is off and there is no hurry to begin addressing ICD-10. Organizations may be planning to complete design, coding and internal testing of the new HIPAA transaction version 5010 before beginning analysis of ICD-10. However, based on industry estimates and some early analysis by health plans, ICD-10 implementation is a lengthy process and organizations will need all the time available under the HIPAA rule’s compliance date. In addition, many business and strategic decisions will need to be made early on. Design decisions made during 5010 compliance efforts may impact ICD-10 as well. Understanding the impacts of ICD-10 and its relation to 5010 and to business processes will help organizations to prepare more effective and efficient compliance plans.

10. Can my vendor take care of ICD-10 for me?

Not all of it. Software vendors will need to upgrade their products to support ICD-10, including features such as drop down menus and selection edits to help prevent incorrect coding decisions. These features can help reduce the impacts of ICD-10, but there will still be business impacts that the vendors cannot mitigate. For example, provider organizations must change their documentation practices to capture necessary data (e.g. left versus right side) to support the more specific diagnosis codes. Software used at point of care will require providers to capture and enter the appropriate granularity into the practice management system or electronic health record. The use of prompts may help guide collection of needed data. Health plans must determine how their coverage, reimbursement, fraud and abuse tracking, and quality measurement activities will change based on the information contained in the ICD-10 diagnosis and procedure codes. The critical changes in the code sets are greater specificity and information in the codes that can impact business practices – not simply the change in format.

11. Can crosswalks between ICD-9 and ICD-10 solve my problem?

Crosswalks may be a part of the solution, but will not enable use of the greater information contained in the ICD-10 codes. Because of the code set differences, mappings do not provide an equivalency in a large number of instances. The intent of mapping is to assist the user in comparison of large, historical ICD-9 data sets to ICD-10; for the most accurate code assignment, ICD-10 and its Official Guidelines must be applied.

HIPPA 5010 & ICD-10 FAQ's for C-Suite at Healthcare Product Development Company:

Technology Focus: CIOs

1. Why must our provider and payer customers’ information systems be both HIPAA 5010 and ICD-10 ready?

Version 5010 of the X12 standards, the updated version of the HIPAA electronic transaction standards, sets the stage for ICD-10 and must be adopted before the ICD-10 code sets. Consequently, version 5010 testing and readiness by your provider and payer customers will be keys to ICD-10 implementations.

The current transaction, version 4010A, lacks the means to identify the code set being used on the claim. Since version 5010 will be used to report codes from either ICD-9-CM or the ICD-10 code sets, depending on the date of service, version 5010 has added a qualifier or “flag” (i.e., increased the field size by one-digit) indicating which code set is being used / has been identified.

Also, for the required Present on Admission (POA) indicators, version 5010 separates diagnosis code reporting by principal diagnosis, admitting diagnosis, external cause of injury, and reason for visit. Currently, your provider customers must place the POA indicators in a string of diagnosis codes in an unassigned segment on the claim that are not clearly distinguished by type and can result in associating the indicator with the incorrect diagnosis code.

In addition, version 5010 has increased the ICD-10 code field size from 5 to 7 bytes and increased the number of diagnosis codes allowed on a claim.

2. Must our company modify the other diagnosis and procedure coding systems, such as CPT and HCPCS, which also are embedded in many of our company’s information systems?

CPT and HCPCS coding systems have NOT changed. Consequently, all of your provider customers currently using and reporting CPT and HCPCS codes will continue to do so. This includes physician and professional services, hospital outpatient departments, outpatient facilities, and all other outpatient services.

Physician offices and other Medicare Part B providers will only be changing to ICD-10-CM and NOT to ICD-10-PCS. CPT is staying because there are no changes to the reporting of CPT codes for Part B providers.

3. What exactly needs to be modified for ICD-10 in our existing information system products?

Your existing information system products will need to modify the following:

• Field size expansion
• Alphanumeric composition
• Use of decimals
• Redefinition of code values
• Longer code descriptions
• Edit and logic changes
• Modification of table structures
• Expansion of flat files* that contain diagnosis and procedures codes

* Documents that contain diagnosis and procedure codes, such as a transcribed Discharge Summary document or an Operative Report document, and have been saved as “text only” or without formatting, are saved without mark-up tags and formatting elements. Such flat file documents only contain the lines of text without regard to the visual presentation of the data on the page and will need to be modified. Consequently, any part of a system that currently uses ICD-9-CM codes will need to be modified to accommodate ICD-10-CM/PCS codes.

4. Are there organizations that are not required to migrate to ICD-10-CM/PCS on the 10/1/2013 compliance date? If yes, it appears as if our company will need to support ICD-9-CM / PCS codes beyond the compliance date.

There are non-covered entities for which the HIPAA transaction and code set modifications do not apply, such as no-fault insurance and worker’s compensation. However, the last regular update for ICD-9-CM codes will be 10/1/2011. Therefore, those codes will be outdated for long-term use by these organizations, and these organizations will need to convert to ICD-10 at some point to maintain a viable business model. In addition, ICD-9-CM codes will need to be maintained by HIPAA-covered entities for the timeframe prior to the 10/1/2013 compliance date for system rebills.