New Year’s Resolution: No More Harping

By: Ron Mills

A well-understood maxim among software developers states that there is generally a difference between:

• what users say they want
• what users want
• what users need

The difference between the first two is one of communication and is easily solved by quickly prototyping what they say they want, so they can say “that isn’t what I want” and start pointing.

The chasm between want and need is much harder to bridge. In the short term, you can make plenty of money giving people what they want, but if you are in the game for the long haul, you ignore the difference at some peril to your reputation. When the system you build fails to solve their problem, are they more likely to come back and say “let’s try again” or will they go somewhere else?

Knowing what the user needs isn’t so easy, of course.

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.

ICD-10: Why Bother?

By: Ron Mills

The forces that would delay the implementation of ICD-10-CM/PCS past October 1, 2013, have been in the ascendency lately. Just last month they were joined by no less an august body than the AMA, who argued that ICD-10 coding does not improve patient care, and that the (we think, highly over-estimated) cost of conversion might be better spent on something that does, like electronic health records.

A much loved tactic in this discussion is to find ICD-10 codes that are unlikely to be of any practical value in the U.S. and throw them out as illustrations of the way we are spending your tax money on unnecessary bureaucratic encumbrances. Consequently, people have been asking us for counter-examples: snappy new ICD-10 codes that obviously improve patient care and make their ICD-9 ancestors look shabby.

I’m not going to come up with any. Partly because I disapprove of this mode of debate. You fling your anecdote at me and I fling mine back, and the side with the best-flung mud wins. But mostly because a classification system doesn’t operate in such a simplistic way.

ICD-10 Scare Tactics

By: Ron Mills

At AHIMA earlier this month, I kept seeing and hearing assertions that went something like this:

Because ICD-10 is so much more complex and demanding, your coder productivity is going to drop dramatically (requiring you to add coders or lose revenue) unless you buy [the speaker’s] new coding technology.

I’m all in favor of technology that improves the accuracy, reduces the cost, or diminishes the tedium of coding. But the statement that ICD-10 is so much more complex and demanding is just not true.

Worse, it is becoming the dominant meme. People who have never opened a code book hear it, believe it, and pass it on. Pretty soon it is echoing down the corridors of power and we start getting rumbles again about putting off the conversion. Puh-leeze. This has got to stop.

Let’s examine the facts. Start with diagnoses. Open an ICD-9-CM code book and an ICD-10-CM code book and put them side by side.

ICD-10-CM/PCS MS-DRG Grouper Q&A Part 1

By: Ron Mills

Since the series on the ICD-10 MS-DRG grouper, I’ve been getting some good questions about it in email, so I propose to share some of the answers in this space. So here we go with caller number one:

I wish to test the ICD-10 MS-DRG grouper from NTIS on patient records from my facility. Must I choose among all the ICD-10 alternatives for each ICD-9 code or should I take all possible combinations suggested by the GEMs? If I have to choose, can I just run the Reimbursement Map backwards on the ICD-9 data?

ICD-10-CM/PCS MS-DRG Grouper Part 4

By: Ron Mills

It may be possible to infer a complete and accurate representation of the MS-DRG Grouper from the Definitions Manual posted on the CMS Web site, but I’ve never counted on it. Instead, I’ve always used the so-called EBCDIC Tables, included with the NTIS distribution of the mainframe grouper.

ICD-10-CM/PCS MS-DRG Grouper Part 3

By: Ron Mills

In Part 2 we explained that the ICD-10 MS-DRG grouper is an attempted replication of the ICD-9 MS-DRG grouper: it tries to get the same DRGs for a record correctly coded in ICD-10 as it would have if the same record had been correctly coded in ICD-9.

Our thought process, as we programmed the computer to build the replication, was this:

1. The ICD-10 grouper will be receiving ICD-10 codes. It has to know what to do with them.
2. Consider each of the roughly 140,000 ICD-10 diagnosis and procedure codes. For each code, ask: “For each MDC where this code may be on the patient record, what ICD-9 code would have been used if the record had been coded in ICD-9?”
3. Answer the question using the 10-to-9 GEM. (You’re starting with an ICD-10 code, right? You need to see all the ways it might be expressed in ICD-9.)
4. Program the ICD-10 grouper to respond to your ICD-10 code the same as the ICD-9 grouper responds to the GEM-associated ICD-9 codes. (If there is a conflict, use clinical judgment or go with the most frequently occurring alternative.)

ICD-10-CM/PCS MS-DRG Grouper Part 2

By: Ron Mills

Since Part 1 was posted, our paper with full details of the MS-DRG impact study has been updated and published in the Medicare & Medicaid Research Journal and is available at http://www.cms.gov/MMRR/Downloads/MMRR001_02_A02.pdf.

I want to continue the discussion of grouper architectural changes we started in Part 1, but to justify the biggest innovation – code clusters – I first have to supply some background. We identify four ways to convert an application like MS-DRGs from ICD-9 to ICD-10:

 

ICD-10-CM/PCS MS-DRG Grouper Part 1

By: Ron Mills

During the first week of May, Anne Boucher and I gave a presentation at the WEDI conference in Seattle, featuring the construction and testing of the MS-DRG grouper and the financial impact of the switch from ICD-9 to ICD-10 on MS-DRG mediated hospital reimbursement. Liz McCullough and I had given roughly the same presentation at the CMS C&M meeting in September 2010; Liz repeated it at the AHIMA ICD-10 Summit in April 2011, and I’m giving it again (it gets better every time) at the AHIMA Convention in Salt Lake City this coming October.

We obviously think this is important stuff. The full text of the original is buried in the middle of the September 2010 C&M meeting handout, which you can find at http://www.cms.gov/ICD10/11b_2011_ICD10PCS.asp. For those of you interested only in the bottom line, it is this: on average, the financial impact to IPPS from the switch to ICD-10 is predicted by our modeling to be about a nickel more per every $100 of inpatient reimbursement – practically speaking: revenue neutral.

Of course, you-know-who is in the details. I’m going to use this and my next few turns in this space to talk about some of them, especially some which we didn’t have time in the presentation to reveal. The MS-DRG grouper is not only an important cog in the U.S. health care reimbursement machinery – it is also representative of any complex ICD-9-based application that has to be working with ICD-10 data by October 2013. Today, however, we’ll look at something unique to the grouper: its architecture.

Translation Terminology

By: Ron Mills

“When I use a word,” Humpty Dumpty said, in a rather scornful tone, “it means just what I choose it to mean, neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

Those of us who have fallen down the rabbit-hole into the world of the ICD-10 transition are feeling Alice’s pain.  Here are some of the worst: