As your company plans the move from ICD-9 to ICD-10, now is a good time to examine whether you are planning for proper use of procedure codes.   ICD-9 based claims may or may not contain this data.  If you work with a health care provider and in particular a hospital, consider the possibility that providers will be required by payers on an increasing basis to include procedure codes on all claims in the future.  If you are a health care payer, these procedure codes and the analytics can help provide better information on reimbursement levels.   For both entities, procedure codes will impact contract renegotiations in the future.

One reason for this is that ICD-9-CM in some cases has a “not otherwise specified” (NOS) coding option. NOS options in ICD-10-PCS are restricted. A minimal level of specificity is required for each part  of a procedure.

The ICD-10 Procedure Coding System (ICD-10-PCS) succeeds Volume 3 of ICD-9-CM.  The new coding system uses 7 alpha or numeric digits while ICD-9-CM  uses 3 or 4 numeric digits. ICD-9 is over 30 years old and does not use current terminology or provide enough detail on the in patient’s medical condition or procedures performed.  We have heard from some companies that they believe that the move to ICD-10 will be easy because they will simply ask IT to lengthen the size of the fields which contain this data.  Unfortunately it isn’t that easy.

At times, an ICD-10 assessment by a knowledgeable third party can encourage different teams to improve communication and discover hidden assets that are under utilized.  It may very well be that valuable procedure code data is contained in the raw EDI files your company sends or receives, but it may not be stored or used for analysis.  Maximizing the use and analysis of existing data can strengthen your organizations’ planning and have a favorable revenue impact.

Indeed, payers should start requiring procedure codes and diagnosis codes on hospital claims to validate exactly what they are paying for.  We recommend to our clients that they begin a study to collect and analyze procedure code data from hospitals, and develop alternative reimbursement models based on ICD-10 codes, CPT, DRGs,etc.

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