ICD-10-CM/PCS MS-DRG Grouper Q&A Part 2

By: Ron Mills

“Mike” wrote Rhonda:

I saw a good article you wrote in The Journal of AHIMA … been very helpful … but the bigger question we are encountering is the continuity of reporting from ICD9 to ICD10. I am hoping you may be able to point me in the direction of any work that has been done on supporting data warehousing, reporting and information challenges when the data spans 2013 and the ICD-9 and ICD-10 code sets.

Rhonda passed it on to me and I responded:

Mike, you’ve got a good* problem on your hands. Here’s what I’ve been doing with the mixed ICD-9/ICD-10 databases I’ve been dealing with, those behind the extension of our products to handle ICD-10. I keep the database structure the same, but recode the ICD-9 codes so they don’t overlap with ICD-10. (See my “False Friends” blog for details.) I put “9$” in front of ICD-9 diagnoses and “I$” in front of ICD-9 procedures, so they can live in the same places as ICD-10 — the ICD-9 becomes an extension of ICD-10 in this system. Since there are roughly 140,000 ICD-10 codes and only about 17,000 ICD-9 codes, that is only a 12% increase in the number of codes being considered. Since code types are not ever mixed at the record level, a code type indicator in the record serves as well, but may require more complicated selection logic.

Since rarely does analysis go down to the individual code level, I make sure any analysis tool I use is upgraded to handle both ICD-10 and ICD-9. For example, analysis by DRG is accomplished by feeding the ICD-9 codes to an ICD-9 grouper and the ICD-10 codes to an ICD-10 grouper, and the groupers make sure the DRGs produced are as consistent as possible. Other vendor’s tools should be available soon which do the same.

When analysis is required at the code level, the record selection (the “where” clause) is merely extended to include both ICD-9 and ICD-10 codes characterizing the patients to be included. We use, through our tools, the General Equivalence Mappings (GEMs) on the CMS web site, to help our analysts decide which ICD-9 and ICD-10 codes to use to select cases and make inferences.

In order to test our ICD-10 products, we’ve had to build a system to translate ICD-9 test cases into “equivalent” ICD-10. It took months of programming and clinical effort to produce something that worked well, and the experience taught us that the result is only useful for testing inpatient groupers and their derivatives. A “one size fits all” forward translation of ICD-9 worth using would require a massive clinical and engineering investment, with no guarantee of success and formidable legal liabilities.

Some other companies claim to have forward mappers but I’ve not seen their products in any detail. I’m skeptical but I’m not in a position to claim they haven’t pulled it off. So you might want to give them a look.

Meanwhile, hang on to your ICD-9 coded data. It ain’t ICD-10 but it’s what you’ve got.

*good. Mike wrote back that I should have said “interesting problem” instead of “good problem.” A good problem, he wrote, “is when I’m given both a Mercedes and a Lexus but I have only one space in my garage.”

And now I’ll indulge myself in some esprit d’escalier. I should have brought up the “garbage codes” argument. Coders often refer to codes with “unspecified” or “NOS” or “NEC” in them as “garbage codes”, the ones you use when the documentation doesn’t specify something it should have. (I would not suggest it may also mean “the ones you use when you’re in a hurry and you know the reimbursement system doesn’t care.”) Whereas ICD-10-CM diagnoses carry on the tradition of garbage codes from ICD-9-CM, ICD-10-PCS procedures do not. So adding the 3,838 ICD-9-CM procedures codes to the 71,918 ICD-10-PCS procedure codes, an increase of only 5%, provides a rich set of garbage codes for the era before ICD-10-PCS precision became the norm. If you have mixed ICD-9 and ICD-10 in your database and you want to cast a wide net, include the garbage codes. If your focus is narrow, include the good codes, and if your focus is so narrow that only ICD-10 can represent it, use only the good ICD-10 codes.

Ron Mills is a Software Developer for the Clinical & Economic Research department of 3M Health Information Systems.

3 responses to “ICD-10-CM/PCS MS-DRG Grouper Q&A Part 2

  1. There are 2 issues that I would like 3M to address in regards to ICD-10-CM/PCS implementation.

    1. According to CMS Final Rule, non- covered entities such as Workers Compensation and Motor Vehicle insurances are not required to change to ICD-10-CM/PCS, how will 3M accommodate the need to code some cases with ICD-10 and others with ICD-9. There is no timeline for this so they could never be mandated to change.

    2.ICD-10-PCS is being implemented for all inpatient claims as of October 1, 2013 but is not required for outpatient claims. In order to reduce the amount of training for our Outpatient coders and to help with the decrease in productivity we have decided not to put ICD-10-PCS codes on our outpatient claims and would like to know how 3M will accommodate this so that the coder does not have to go through all the logic for ICD-10-PCS codes for outpatient claims.

  2. These questions pertain more to 3M’s Coding and Reimbursement systems than to just the MS-DRG grouper. I don’t feel qualified to provide as accurate or complete an answer as the questions deserve, so I’m forwarding them to the experts who are, and I’ll post their answers here when I get them. With respect to the grouper, however, it is our hope and expectation that version 31 (the FY2014 version effective October 1, 2013) will be defined in both ICD-9 and ICD-10, so non-Medicare users of the MS-DRGs will be able to compute comparable DRGs for ICD-9 claims. (Medicare will only be accepting ICD-10.) Version 32 will probably not be defined for ICD-9 (though, as Yoda says, “difficult to see, the future is”) so non-Medicare DRG reimbursement systems will be stuck at version 31 until they go to ICD-10.

  3. Our Coding & Reimbursement folks provided this response:

    The 3M Coding and Reimbursement System (CRS) can be configured to provide ICD-10, ICD-9 or dual coding. For example, some facilities will want to have both ICD-9 and ICD-10 codes on every claim regardless whether it is Workers Compensation, Medicare, or Medicaid. This will allow the facility to consistently report across the board on all types of claims. For claims that do not require the ICD-10 codes, only the ICD-9 codes will be submitted for billing. Using the dual coding functionality of simultaneously deriving both code sets via a single logic pathway will provide compliant ICD-9 and ICD-10 codes for future analysis.

    When sites do not collect both code sets on all claims, they can select a “logical” grouper that is defined to use ICD-9 codes for claims with dates after 10/1/2013. This selection of the logical grouper can be done manually or through the interface packets that launch CRS from your abstracting system. For example, through the interface, the abstracting system knows if it is a Workers Comp claim and can send in the necessary items to tell CRS to use the logical grouper configured for ICD-9 codes. When a Medicare claim is selected in the abstracting system, it sends the necessary items to tell CRS to use the Medicare grouper which will use ICD-10 codes for records with dates of 10/1/2013 or later.

    So whether your facility wants just ICD-9 codes on a claim, or both ICD-9 and ICD-10 codes on a claim, or just ICD-10 codes on a claim, the system can accommodate.

    Now to the second question. We have found that some facilities are planning to do just what you mention, not code the ICD-10-PCS codes on their outpatient claims. Other facilities will code both. The system can be configured so that the outpatient products/groupers (i.e., APCFinder) only code just the HCPCS/CPT codes (and hence only use the CPT coding logic pathways and questions to derive only the HCPCS/CPT code). Alternatively, for facilities that want both ICD-10-PCS and HCPCS/CPT codes, the procedure logic pathways and questions will start with the ICD-10-PCS logic, then ask additional questions for the HCPCS/CPT codes.

    Thank you for asking these questions as it lets us know that you are getting ready for ICD-10 and analyzing the impact it will have on your processes.

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