Health Language Blog

The Emerging Role of Clinical Terminology Management for Payers

Posted on 05/03/13 | Comments

With the internal transition to ICD-10 well underway for most payers, now is the time to shift your focus to other industry initiatives, such as Stage 2 Meaningful Use. The move to ICD-10 has provided your organization with a breadth of granular codes, and it’s critical that you determine how best to incorporate these codes in your data strategy in order to maximize the benefits of this detailed patient and billing information.

Along with federal legislation, the rise in health information exchanges, ACOs and health insurance exchanges has shed light on the importance of data normalization beyond ICD-10. With interoperability at the heart of each of these initiatives, payers and providers alike will be required to use standardized terminologies for documenting and sharing patient information. Some of the most significant benefits of clinical terminology standardization and management for your organization in a value-based healthcare environment include:

  • More timely and accurate provider reimbursement due to consistent code usage;
  • Decreased administrative costs;
  • Streamlined communication with customers; and
  • Enhanced analytics for identifying cost-effective treatments offered by providers and supporting population health management.

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Topics: ICD-10, HCCs, Medical Plans, LOINC, medical terminology management

Impact of Analytics on Medical Plans & Policies

Posted on 01/23/13 | Comments

One of the most common questions that we hear from current and prospective clients is, “What are payers doing to prepare for the transition to ICD-10 CM/PCS?”  My response to that question has changed over time as payers who have already dived into the new code set begin to identify the immense opportunities available with the more precise codes available in ICD-10 CM/PCS.  Initially, most LEAP I-10 users were focused on strictly translating codes from I9 to I10, and some early adopters even anticipated a best one-to-one match between the code sets. 

Now we see more experienced ICD-10 translators and analysts thoroughly evaluate the nuances of the new code descriptions.  Payers are recognizing that some of the ICD translations will require greater precision in documentation and many that significantly impact reimbursement.  For example, in ICD-10, there is further specificity in factors such as acuity and site of disease; causative agents, drugs, diseases, and genetics; and expanded surgical approaches that impact the intensity of service provided.  A provider can now distinguish between and reimburse accordingly for a condition of the peritoneum versus the retroperitoneum with the latter condition resulting in a higher-weighted MS-DRG. Another option many payers are considering is the exclusion from coverage newly available information related to patient ownership of a disease condition such as alcohol-induced chronic pancreatitis, or intentional poisoning codes. 

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Topics: Medical Plans, Payers, Analytics