The Business, Process, People and IT Implications of ICD-10
cheryl wilson 270003VHSH firstname.lastname@example.org | | Tags:  business-events business-rules decision-management business-process-improvem... icd-10 healthcare-regulations bpm compliance
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If you read our earlier, lighter post, Are You Ready for the Pain of ICD-10, or you’re in the healthcare industry, you’re familiar with ICD-10. As a quick refresher, the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) has mandated that healthcare providers and payers transform their diagnosis and treatment coding from ICD-9 to ICD-10 by October 1, 2013. ICD codes are fundamental to decisions regarding healthcare claims, pre-authorization and eligibility; and they drive billing, reporting and analytics. This code transformation, which already has been implemented by many developed countries worldwide, will enable more accurate recording and reporting of pathology, care and treatment because the ICD-10 coding scheme is approximately five times more extensive than its predecessor. Ironically, it’s the beneficial characteristics of the new code scheme that give rise to a transition plan that is both extraordinarily complicated and necessarily rigorous.
The ICD-10 transformation regulations have many business, process, people and IT implications. Undoubtedly, plans/payers will retain some legacy IT systems using ICD-9 beyond the 2013 milestone because of the estimated cost and duration of effort required to modify them. Therefore, methods for mapping from ICD-10 to ICD-9 will be required in order to enable timely compliance with the implementation schedule. However, “cross-walk” mapping and other methods for conversion between the two code schemes is also complex because of the relationships between the 30,000 codes in the ICD-9 scheme and approximately five times that number in the ICD-10 scheme. The possible combinations range from “one-to-none” to “one-to-many” and “many-to-many.” Further complicating the problem, many pathologies and procedures have only approximate or ambiguous equivalents from one code scheme to the other, so mappings and simple look-ups are typically insufficient and not so simple. Therefore, deliberation among subject matter experts (SMEs) is often required for code translation, exacerbated by the fact that missing or uncertain translations occur randomly and unpredictably in a typical healthcare claim transaction stream, and correct code selection has signification revenue implications.
Why you need more than just BPM for ICD-10 compliance. For healthcare providers and payers to become ICD-10 compliant, it’s less painful when there’s a business process management (BPM) solution that provides the flexibility to migrate and update back-end systems and data warehouses to ICD-10 as dictated by business priorities. The most cost-effective and potentially successful ICD-10 BPM-based transformation tactics include some level of decision management (DM) capabilities – more specifically, the application of business events and business rules to determine the “when” and the “what” of particular actions (e.g. detect and notify SMEs of a code incompatibility for deliberation and determination).
Here are some of the ways that Decision Management can help.
For more information: To learn more about IBM healthcare provider and payer solutions and the IBM Transformation Accelerator and Manager for ICD-10, contact your IBM representative or IBM Business Partner, or visit: ibm.com/software/industry/healthcare and http://www-01.ibm.com/software/industry/healthcare/ICD_10/
To learn more about how decision management capabilities can ensure compliance, download this white paper: Becoming a Decision-centric Enterprise.
This post was contributed by one of our guest bloggers, Pete Melrose, Worldwide WebSphere Industry Marketing Manager, Healthcare & Life Sciences.