ICD-10 Impact for Payers

The switch to ICD-10 will affect all major functional areas and interfaces. Payers use diagnosis and procedure codes when determining member eligibility for treatments, establishing fee-for-service reimbursement amounts, submitting coordination of benefits reimbursement requests from other payers, identifying potential subrogation cases, and auditing for suspected cases of fraud. ICD-10 will enable payers to make more precise determinations in these and other areas.

After making system and process modifications to accommodate the 5010 electronic transactions, payers will have to remediate, upgrade, or replace non-compliant claims adjudication systems, conduct a major underwriting initiative to develop new fee schedules, and overhaul reporting to take advantage of the detail provided by ICD-10 codes. Payers are the key to making the introduction of ICD-10 into the US a move that drives cost reductions and improves health outcomes.