My shameless plagiarism aside, the question about the transition from ICD-9 to ICD-10 is definitely being asked in all the circles of healthcare industry, from payers to providers, from IT to business, from CIOs to those medical policy reviewers who actually have to ascertain the medical necessity of the procedure. And trust me, there is no consensus. Did you think for a second that there will be? If yes, then you must not have been living in US and sure as heck, have never been to a hospital or gotten an explanation of benefits.
I have participated in mild, civilized discussions about the topic and I have been an unfortunate middle man in mud-slinging matches where blood-letting was avoided only due to lack of sharp objects in the room and the width of the table. So why is the topic so explosive and is there a final conclusion? I definitely don’t mean a consensus, neither am I naïve enough to hope for one. Just a simple majority-supported conclusion. And once the question of cross-walking has been answered, will there be a standard implementation approach that will be adopted by the industry?
First question, first. At the risk of going through my own March of Ideas, I propose that a crosswalk is going to be mandatory requirements come 1st of October 2013. I will try to plead my case using certain business scenarios here, and not simply point you to what the analysts have been saying, though more and more of them are leaning towards a crosswalk based solution. And so are the executives.
Let’s take a simple example. Let’s assume that through some miracle, every single one of the payers and every single one of the providers is ready with ICD-10 codes on 1st October 2013. What more, let’s assume that they can actually code in ICD-10 without much of a productivity loss. Obviously this scenario will rule out the crosswalk. Or would it? Let’s now fast-forward to 1st of April 2014 (I think I am watching too much of the ABC show ‘FlashForward’). A large employer comes to a payer and asks for a quote for insuring 150k employees of theirs. What does the payer do? To quote, one needs historic data and at that point of time, the payer has 6 months of historic data in I-10 and 20 years of historic data in I-9. One can’t ignore the 20 years of history because of chronic trends and one definitely can’t ignore the latest 6 months.
And you thought that the job of actuaries was difficult now. The only option at that point is to have some kind of harmonization to be done on the two historic data sets. Well, there is your crosswalk. Granted, it is not an in-transaction crosswalk wherein one has to convert an inbound claim from I-9 to I-10, which requires a heck of a lot more accuracy, but still it is a crosswalk nonetheless. It could be a statistical trend based crosswalk using some kind of weights, but it will be a crosswalk.
Let’s take another example, wherein a pre-auth comes in before 1st October 2013, for a long-term procedure, say maternity. The actual procedure takes place post the transition date and the claim comes in after 1st October 2013. How does one validate the medical necessity or even reconcile the claim against the prior auth. Well, one needs a crosswalk. Maybe not a very exhaustive one, may not even be a clinical rules based, but a crosswalk all the same.
Also, the conservative estimate in the industry is that around 60% of the providers are not going to be ready with I-10 on the transition date. Even if I take 50% of that, we are talking about close to one third providers not being able to generate I-10 codes. So what is one going to do? One is within the legal rights to reject those claims but can one afford to do so and in the process push those already-cash-starved providers to bankruptcy. What happens to the healthcare system in the country under that scenario? So, methinks, even an in-transaction crosswalk is definitely in play to avoid such massive anguish across all stakeholders.
On the provider front, if one needs to leverage the massive knowledge of coding that has been built over the years of I-9 usage in order to avoid the great productivity loss (Australia and Canada being prime examples), one must have a crosswalk to transition the I-9 codes to I-10 codes. Also, if one wants to maintain any kind of consistency in their clinical decision support systems (that leverage historic clinical data) or still provide effective EHR support, one better figure out how to harmonize historic data. And as of yet, the answer seems to be a crosswalk and this time the real complicated one, i.e. clinical rules based.
And I have not yet talked about the benefits of the crosswalk, pre and post transition date. In a previous post I had talked about contract negotiations and payout/reimbursement neutrality. There is no better mechanism than using trends/weights based crosswalk-driven simulation model to figure out the potential impact on payout and/or reimbursement, depending upon from which side of the table one is looking at it.
Also, the possibility of doing extremely granular stratification of member population for disease management purposes while maintaining administrative simplification for financial purposes, is a definite possibility with the use of a well-designed crosswalk
Now on to the second question, i.e. Is there going to be a national cross-walk? Methinks, it is just a pipe dream. It is extremely difficult to establish a consensus across such a gargantuan landscape of varied stakeholders. In any case, the situation will vary from payer to payer and provider to provider. Even if the business scenarios were not that discrete, who will take up such a massive undertaking of creating and maintaining such a crosswalk, and by the way take abuse from every conceivable stakeholder in the process. What a thankless job that will be.
I believe that there will be multiple crosswalks, dependent upon business parameters, lines of service, contract structures, and last but not least appetite for inaccuracy in auto-adjudication. There might be community based or association based crosswalks (such as Blues might all join hands) but even those will have their own variants at each individual organization.
So, bottom line? Be ready for a crosswalk, whatever shape or format and start planning towards creating one of your own, lest you end up using one that aligns to your business like BP’s oil rigs to the Gulf coast shrimp business.
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