Revenue cycle impact: what is known about payment

Payment: what we know, and what we don't

On payment, we know the process. The financial effect is still an open question.

Rulemaking comes first

ICD is a HIPAA-designated code set used in billing and payment. HHS regulations make its use mandatory, so a change needs federal rulemaking. The last change, to ICD-10, reached morbidity use in 2015, twenty-five years after WHO endorsed it.

• Step 1 · Code set · ICD is a HIPAA-designated code set used in billing and payment processes.
• Step 2 · Change · HHS regulations make its use mandatory, so a change needs federal rulemaking.
• Step 3 · Precedent · ICD-10 reached US morbidity use in 2015, 25 years after WHO endorsed it.

What WHO says about grouping

WHO notes that DRG grouping logic may need review, to decide whether cluster coding can be used in the grouper or the clusters must be unbundled. And that countries should rely on crosswalks for a suggested two years before refining their DRG classification.

• Review · Grouper logic · DRG grouping logic may need review to decide whether cluster coding can be used or clusters must be unbundled.
• Crosswalks · Two years · Countries should rely on crosswalks for a suggested two years before refining DRG classification.

The financial effect is unknown

The financial effect is still open. NCVHS lists the impact of reimbursements based on ICD-11 versus ICD-10-CM among the US interests not yet resolved, and we found no published US estimate.

• Listed · As open · NCVHS lists the financial impact of reimbursements based on ICD-11 versus ICD-10-CM as a US interest not yet resolved.
• Our reading · No figures · We found no published US estimate of the effect on payment.

Check yourself

Pause and think. What does WHO say about DRG grouping logic? The answer: It may need review to decide whether cluster coding can be used or clusters must be unbundled. WHO notes that DRG grouping logic may need review to decide whether cluster coding can be used in the grouper or the clusters must be unbundled.

• It never needs review
• It may need review to decide whether cluster coding can be used or clusters must be unbundled
• It should be removed
• It must always unbundle clusters

Keep these in mind

Payment changes need federal rulemaking. Groupers may need review for clusters. And the financial effect is not yet known.

• Payment changes need federal rulemaking
• Groupers may need review for clusters
• The financial effect is not yet known