ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The deadline for the United States to begin using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding is currently October 1, 2014. The deadline was previously October 1, 2013. All HIPAA “covered entities” must make the change.
They might not have to play by all the same rules, but healthcare providers should not forget the impact ICD-10 will have on non-HIPAA covered entities such as workers compensation, nursing homes, and home health agencies. While non-HIPAA entities are not mandated to switch to the new code set on October 1, 2014, the changing tide will sweep them along with the complex transition whether they like it or not. Medical providers should be aware of the struggles of their non-HIPAA partners, especially as the care coordination spectrum expands to include more and more external organizations that may not always be on the same page.
It may seem like those entities that are allowed to stick with ICD-9 would be happy to do so. But in fact, staying with the old code set, which will not be maintained or updated after 2014, might be more trouble than it’s worth. Technically, workers compensation insurance could demand all provider claims to contain ICD-9 codes for as long as they please, but the undue hardship that would place on medical professionals has been deemed too great by some large insurance plans such as the Ohio Bureau of Workers Compensation (OBWC), which is planning to use ICD-10 after the implementation date.
Non-HIPAA entities could also choose to accept ICD-10 codes from providers but crosswalk them back to ICD-9 if they don’t want to upgrade their systems. But the extra work to create accurate and reliable mappings from a very detailed code to a broader ICD-9 one seems a little pointless. “Even though claims professionals don’t have to be immediately fluent in ICD-10, they should be forward-thinking and follow the market in the direction it’s headed,” suggests John Sarich, VP of Strategy for VUE Software in a post for Claims Journal. “It will require some upfront investment, but will ultimately outweigh the lost time that accompanies translating every medical record you encounter.”
And payers such as workers compensation and property and casualty insurance do have a vested interest in the detail and specificity provided by ICD-10, mandate or no. They will spend less time pestering physicians for more and more documentation to validate a claim for an injury, reducing the administrative burden for everyone involved – assuming payer claims processors are properly trained in the new code set and don’t need to return to the provider to ask for clarification.
Insurance industry groups have been planning for the ICD-10 switch alongside their medical peers, with major organizations such as the Work Loss Data Institute and the National Council on Compensation Insurance updating their documentation and handbooks accordingly. But just as medical providers and payers are struggling with the requirements for the complex and costly transition, non-HIPAA entities are also facing challenges.