Processing
Scenarios
1. Category of
Service (COS) and Cost Center determination logic often uses diagnosis codes to
determine COS’s like Family Planning, etc.
2. Medical Policy criteria,
Medical Benefit limit parameters (aka. Accumulators) and Claims Utilization
Review (UR) modeling and reporting can include/exclude a range or a list of
ranges of diagnosis codes.
3. Early and
Periodic Screening, Diagnostic, and Treatment (EPSDT) processes use various
diagnosis codes for comparisons and setting of various indicators that
determine whether and how claim should be processed.
4. Claims history
searches and queries include ICD-9 diagnosis codes. Logic used
to select records from claims history spanning the ICD-10 implementation date
will have to address selection of claims based on both ICD-9 and ICD-10 code
equivalents.
5. “Provider Watch”
logic typically allows providers to be put on review for a single diagnosis or
range of diagnosis codes.
6. Retrospective
Third Party Liability (TPL) mass adjustment processes posts certain edits based
on the diagnosis codes present on a claim to determine whether to create TPL
billing records.
7. Diagnosis Related
Group (DRG) pricing logic uses diagnosis codes as input for the grouper/pricer
function.
Remediation
Patterns
1. Use a mapping crosswalk to backward convert
ICD-10 diagnosis codes to their ICD-9 equivalent code and then use the ICD-9
code to determine whether the criteria applies.
2. Force user to supply an ICD-10 code and
backward convert the I-10 code to its ICD-9 equivalent(s) for comparison
purposes during the history profile selection process.
3. All existing diagnosis reference files records
must be effective dated with ICD-10 codes used starting on 10/1/14.
4. Modify code selection to determine which code
- ICD-9 or ICD-10 – to use based on a date of service (professional) or
discharge date (institutional).
So when you are designing your
remediation approaches for the ICD-10 mandate, consider how common remediation
patterns can be employed.
