Managed Care - December 2008 - (Page 12)

Countdown Nears For Launch of ICD-10 This new code set promises to delineate like never before the type of physician service rendered By Frank Diamond Managing Editor ook to the blue horizon and behold the biggest systemic and technological challenge in generations. The implementation of ICD-10 codes will change forever the way medical directors, hospital officials, physicians, and everybody else in health care conducts business. It’s out there, all right. But how far off? The transition from ICD-9 that’s mandated by the government could well occur on Oct. 1, 2011, the proposed deadline as of this writing. Or, if health plans, hospitals, physicians, and almost everybody else outside of the Centers for Medicare and Medicaid Services get their way, it might not happen until 2013, or 2015, or 2016. We’ll very possibly know the deadline by the end of this month, when CMS is scheduled to issue the final regulation. One thing we know for certain: ICD-10 will mean buying into information technology in a way that has not happened up until now. “I’ve watched the ICD-10 storm cloud approach slowly and learned it will require some extensive retooling in claims processing, actuarial services, and finance,” says Jaan Sidorov, MD, a consultant, former health plan medical director, and member of MANAGED CARE’S editorial advisory board. “From a medical director’s point of view, there are implications for network management (will the providers submit claims correctly?), disease and/or care management, and HEDIS. The fear is that not knowing how to navigate the codes will result in rejected payments and/or loss of income because of unintentional down-coding.” There’s little question that the transition is well overdue. “Most parts of the health care industry agree that this needs to be done and that the real discussion is what’s the timing for it,” says Karen Trudel, the deputy director of the office of e-health standards and services at CMS. ICD-10 (the International Statistical Classification of Diseases and Related Health Problems 10th Revision) is the latest code set from the World Health Organization to categorize diseases. It is overseen in this country by the Department of Health and Human Services (See “ICD-10 Beyond Our Shores” on page 19). Periodically, ICD goes through major revisions. In between, there is a continuous updating of particular codes, as well as the addition of a handful of new ones each year. “Those interim revisions have been well supported by software that was designed to anticipate such annual updates,” says Charlie Baker, the chief executive officer at Harvard Pilgrim Health Care. “ICD-10, however, represents a scope of change not attempted since 1946 with ICD-6. Revisions 7, 8, and 9 all deferred any major changes to structure of the codes in deference to significant cost that would be incurred to both paper and electronic systems put in place over the last 60 years. This is the reason underlying the impact of moving from ICD-9 to ICD-10; much to be gained but much to be changed.” To make things even more daunting, HHS wants to also overhaul how pharmacy claims and other administrative transactions are processed by adopting an updated X12 standard, version 5010, which is an electronic format that governs the processing of payment data (See “New Electronic Transaction Standards for Pharmacy” on page 16). L Two groups of codes The ICD codes are actually two separate groups: ICD-10-CM (clinical modification) is a set of diagnosis codes to be used, for the most part, by health plans, hospitals, providers, and PBMs. ICD10-PCS (procedure coding system) put an addi- 12 MANAGED CARE / DECEMBER 2008

Table of Contents Feed for the Digital Edition of Managed Care - December 2008

Managed Care - December 2008 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor ICD-10 Offers Huge Opportunity, Challenge Part D at a Crossroads Plans Can Weather the Financial Crisis DM vs. Medical Home? Tackle Prediabetes Reasonable Approach to Morning Sickness Formulary Files Tomorrow's Medicine Outlook

Managed Care - December 2008

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