Despite past and potential future delays, providers must appreciate that many current managed care agreements likely include binding language that will impact reimbursement changes resulting from ICD-10 implementation, particularly for inpatient services.Coding discussions to date fail to address that ICD-10CM likely will require changes in how plans reimburse for certain services and how coverage is determined.

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Determining the potential impact on Reimbursement:

The first step

Determining the potential impact of ICD-10CM on facility-based reimbursement is to consider which payers will be required to use ICD-10CM codes.A more distant but predictable change related to the extensive code details in ICD-10CM will allow CMS to change to Medicare severity diagnosis related groups (MS-DRGs)to better accommodate more accurate payment.

The Second step

Determines us to consider the current use of ICD-9-CM codes and their impact on all the major payment methods used to reimburse facility-based providers.Examining the number of payment methods that currently utilise ICD-9-CM codes to determine payment reveals that there are a number of payers, provider settings and payment methodologies that will be impacted by the transition to ICD-10CM not just acute-care inpatient Medicare stays.

Some payment methodologies to be impacted by ICD-10 to a greater degree than others are a function of both Inherent and Intentional impact.

Inherent Impact:  Itrepresents compromises a payer must make in converting to the new code sets in an attempt to remain revenue neutral that result purely from the differences between the three codes sets (ICD-9-CM, ICD-10-CM and ICD-10CM-PCS).

Intentional Impact:Intentional impacts will affect both payers and providers to some degree, primarily based on each payment methodology’s dependence on ICD codes to determine payments. Certainly, not all payment methods are based on diagnosis and procedure codes, but those that are will be the most vulnerable to manipulation by payers and providers.

“ICD-10CM -PCS has been developed as a replacement for Volume 3 of ICD-9-CM.The system has evolved during its development based on extensive input from many segments of the healthcare organisation. The multiracial structure of the system, combined with its detailed definition of terminology, permit a precise specification of procedures for use in health services research, epidemiology, statistical analysis and administrative areas. It will also enhance the ability of health information coders to determine accurate procedure codes with minimal effort.”