7 Payer Business Processes Impacted by Diagnoses Codes

Diagnosis codes are used in a myriad of medical claims adjudication and reporting processing scenarios.  Many of these business functions might be addressed by similar remediation patterns.  Here are 7 common business functions that I believe may be remediated with similar approaches – or a combination of approaches.

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.