The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") require the Department of Health and Human Services ("HHS") to adopt national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. A component of HIPAA requires ICD-9-CM code sets used to report medical diagnoses and inpatient procedures be replaced by ICD-10-CM code sets effective October 1, 2015.
While the ICD-10-CM hierarchy utilizes the same structure as ICD-9-CM, the specificity required as a result of the ICD-10-CM migration requires that providers not only educate staff, but also conduct a comprehensive internal assessment of Information Technology and documentation readiness prior to conversion. Utilizing a formal strategic plan and management approach that mirrors the organizations overall culture, will allow providers to ensure the breadth of the impact is fully recognized from a compliance, operational and net revenue perspective.
The greater detail within the ICD-10-CM system also enables providers to capture severity, medical complications, medical safety issues and new technology, all while improving data on outcomes and efficacy. It is anticipated that this will in turn reduce claim denials due to the system being less ambiguous, justify medical necessity for specific services and ensure appropriate reimbursement for new technologies, while also allowing payers and providers to identify patients in need of disease management services.
In summary, the complexity involved in the ICD-9-CM to ICD-10-CM transition is pervasive, effecting clinical and revenue operations to include:
- Documentation in the Electronic Health Record
- Billing and Information Technology Infrastructure
- Accounts Receivable
- Payer Relations
- Net Revenue
- Quality
- Population Health
- Case Management/ Documentation Improvement
- Coding
- Compliance
For these reasons, providers need to be continually aware of the challenges that will be encountered by monitoring, evaluating and educating staff, as well as staying attune to measures that will mitigate risk and allow the facility to remain financially viable post-conversion.
SunStone is committed to assisting our clients navigate these changes and our team of approved American Health Information Management Association ("AHIMA") ICD-10-CM/PCS trainers are here to help!
For more information, please do not hesitate to contact Vonda Moon, Principal, at vondamoon@sunstoneconsulting.com.