Health Language Blog

Impact of Analytics on Medical Plans & Policies

Posted on 01/23/13


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. 

As we move closer to the transition date for ICD-10 CM/PCS, we will see more payers begin to leverage data to galvanize coverage changes that will impact revenue for years to come. It is appropriate that payers and providers equally communicate and continue active and focused transition toward ICD-10 CM/PCS.

Topics: Medical Plans, Payers, Analytics

About the Author

Elaine King