During the industry migration to the HIPAA 5010 transactions set, multiple problems related to insurer edits and adjudication processes arose that were not identified prior to implementation. These were problems that originated when claims management and transactions processing systems were updated, but not found until later.

A session at the ICD-10 Symposium on March 3 before the start of HIMSS13 in New Orleans will walk through the lessons of 5010 and how to avoid related issues that, if not identified early, could occur during the transition to ICD-10. “There may be issues with payer-related edits that could cause delays in processing claims,” says session presenter Mary Rita Hyland, assistant vice president of regulatory affairs at The SSI Group Inc., a revenue cycle software vendor and claims clearinghouse.

These issues already have arisen in early ICD-10 testing between vendors and payers, Hyland says. Payers are all implementing ICD-10 differently; there are no standards on edits and adjudication processes. In testing with one payer by coding claims in ICD-9 and ICD-10 and running them through adjudication systems, SSI found that DRG data associated with contractual arrangements with providers were causing 65 percent of the claims to fail adjudication because the ICD-10 codes were not accurate. There had been changes in groupings of ICD-10 codes when mapping from ICD-9, and the payer had not made the changes.

Another problem that arose in 5010 implementation was that organizational timetables for the project were too rigid and when problems arose and delays came, organizations ran out of time. Providers did not understand that transactions processing timetables will change often, so initiatives have to start earlier than expected to build in time for delays.

The need for flexibility is far greater now with ICD-10, then when the industry upgraded to the HIPAA 4010 and then 5010 transaction sets, Hyland says. Providers are expecting testing to be similar to what they have experienced in the past, and that won’t happen. With the HIPAA transactions, providers or their clearinghouse conducted structured tests with insurers. But not only is ICD-10 obviously far more complex, it also involves so many more stakeholders, and no organization will have the time or resources to test with all their stakeholders.

Just on the payer side, expect different testing approaches by each insurer, Hyland warns. With each insurer it tests with, a provider will code transactions in ICD-9 and ICD-10, and then analyze the difference. What they’ll find out is that the difference will vary with each payer based on their specific edits.

And while many revenue cycle vendors and clearinghouses carried most of the load for providers in the HIPAA implementations, that won’t fly with ICD-10. Providers must embrace their own accountability for ICD-10 success if their claims and related transactions are to go through smoothly, and not count on vendors and insurers to do most of the work, Hyland will stress. “It’s their responsibility to be able to test internally and externally with their trading partners. No one can test for them.”


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