ICD-10 fluency means provider, payer collaboration

The ICD-10 diagnostic code set is a fundamentally different language, which systems, people, and processes at both provider and payer organizations will need to speak fluently by Oct. 13, 2013, Ian C. Bonnet, VP of ICD-10 adoption at WellPoint (NYSE: WLP) told HCON2011 attendees in Washington, DC, yesterday.

Although the transition will require effort, learning the new coding language will prove less costly than trying to avoid fluency, he noted.

To take the fluency process to the next step, healthcare organizations must openly collaborate across all boundaries, said Bonnet. For WellPoint, that means working with its institutional, hospital, and physician partners to determine how new medical policies will affect their operations, the quality of their clinical services, and their customers.

That sentiment was echoed by a fellow panelist addressing the health IT aspect of ICD-10 transformation. Collaboration between providers and payers "is the best implementation route," said Mary Hyland of the SSI Group, a healthcare transaction clearinghouse that processes more than $116 billion in claims each year.

Hyland maintained that communication is vital to moving forward with ICD-10 implementation so that it can improve the use of clinical data by providers and payers across all domains.

What's more, WellPoint found that insulating itself from the ICD-10 language--transforming new data back to ICD-9--led to considerably negative results. By not "communicating" codes appropriately, WellPoint had 50 percent DGR mismatches, and in some cases, over paid providers by 20 percent and underpaid them by 10 percent, which could lead to further financial and legal issues for both parties.

To avoid miscommunication, CMS offers GEMs (General Equivalence Mappings) designed to bridge the language gap between ICD-9 and ICD-10 coding. Although it is a good starting point for ICD-10 fluency, "it's not the end-all-be-all," said Bonnet.

According to Bonnet, payers and providers should refine the general mappings to represent contextual usage in their own health organizations to build fluency.