Donna: Sue, where were you when you first heard the news?
Sue: Well, our D.C. office sent me a heads-up message, so I quickly turned on C-Span and watched the House vote live. It all happened so fast. Within minutes, the bill had passed the House and was moving on to the Senate.
Donna: I was on break at a conference when I got your urgent email. Incredulous is the word that describes my reaction. All I could think about was the years of work providers, payers, and vendors have invested in ICD-10 implementation. And I couldn’t help but think about the time you and I have put into it too. So, where do we go from here?
Sue: There’s nothing left to do but think positive! Continue reading
The death of the October 2014 implementation date for ICD-10 unfolded faster than the plot of a 30-minute sitcom. It started in the House of Representatives on a Wednesday when a provision to delay ICD-10 was quietly attached to bill H.R. 4302, also known as the SGR “doc fix” bill, and it was all over by the following Tuesday when President Obama signed the bill into law. If you blinked, you missed all the action.
Hospitals, payers, providers, and vendors have all invested millions of dollars and countless hours over the past several years getting ready for the transition, and then without notice someone moved the finish line – to October 1, 2015 maybe? Those hospitals who prepared early feel like they are paying a penalty for acting in good faith, while those who procrastinated are feeling vindicated and hopeful ICD-10 will never happen. Continue reading
At the end of Part 9, we were translating a list of ICD-9 codes – a policy – into ICD-10. We used the 10-to-9 single GEMs with reverse lookup to find ICD-10 codes that should be in your ICD-10 version of the policy. We had some ICD-9 codes left over that no ICD-10 code translated to. You tried to look them up in the 9-to-10 single GEMs. You found some translated to ICD-10 codes already in your ICD-10 policy list, so you could feel assured that their meaning was taken care of. A few may have translated to single ICD-10 codes not already on your list. Those ICD-10 codes (“pink” in CTT) might be appropriate for your policy, but a clinical review of them was recommended.
Finding all the ICD-10 codes that might be on a patient’s record, and that might imply the patient satisfies the policy, is the objective of our process. Have we now found them all? Consider this case from Part 10: Continue reading
The time has come to talk about clusters. Back in Part 3 we defined them and in Part 7 we separated the GEMs into single-code and cluster tables. But we haven’t yet looked at them closely. We can’t put it off any longer.
Clusters come into play when something that you can say with one code in one system requires more than one code to say the same thing in the other system. A couple of examples will get us started.
Example 1: One ICD-9 diagnosis
073.0, Ornithosis with pneumonia Continue reading
Lately, OIG is reminding us we can’t seem to comply in ICD-9. I suggest that whatever happens by this time next year, don’t blame ICD-10. Coding is complicated with tons of rules and regulations. And yes, as soon as one learns something new the regulations change and even newer codes, modifiers, documentation, and incantitations are required. It’s been this way for years; and for years there has been noncompliance regardless of the code version. Not news you say? Where am I going with this? I just read another OIG audit report on yet another large provider. It makes me sad to learn they will have to pay back upwards of 1.6 million dollars in over payments for both inpatient and outpatient coding and billing issues. According to OIG, “The errors occurred primarily because they did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas.” Continue reading
In Part 8 we translated a policy by looking up each ICD-9 code in the policy in the “10-to-9 singles map with reverse index” and entered into our ICD-10 version of the policy the ICD-10 codes that were found there. We discovered that not all of our ICD-9 codes were found, and we put them on an “ICD-9 Orphan” list. Now we consider what to do with those ICD-9 codes.
Start by looking them up in the 9-to-10 singles table. If there are one or more entries for the ICD-9 code, it means one or more ICD-10 codes might be appropriate for the policy, given the definition of the ICD-9 code. The emphasis is on “might be” because the GEMs do not know the information in a patient’s chart used to assign the ICD-9 code. Those ICD-10 codes could contain additional meaning that may have been true for a patient, or not, and the ICD-9 code doesn’t specify either way. Continue reading
Donna: Sue, do you know what the UHDDS definition is for a significant procedure?
Sue: Of course! I hate to admit it but I was actually involved with coding issues in 1986 when the UHDDS revision occurred. The UHDDS definition of a significant procedure is a procedure that is one, surgical in nature, two, carries a procedural risk, three, carries an anesthesia risk, or four, requires specialized training. Why do you ask?
Donna: Well because some hospitals are assigning ICD-9 procedure codes for every procedure performed during an inpatient stay. Continue reading
In Part 7 you started with an ICD-9 policy list, and using the “10-to-9 singles map with reverse index” you found all the single ICD-10 codes whose meaning is included in one or more of the ICD-9 codes on your list. In other words, you found all the single codes in ICD-10 that can say what the codes on your ICD-9 policy list say. You wrote those down as a new ICD-10 version of your policy.
In the process, you may have come across … Wait. Is there a hand raised in the back of the class? Yes?
“When you had us write down each ICD-10 code we found using the reverse index, you did not have us write down the ICD-9 code it came from.” Continue reading
We are ready to start translating policies. The first step is easy to do, but difficult to believe in. When I “got it,” it was like one of those optical illusions where the cube suddenly turns inside out. I’ve watched other people see the light. I’m going to try to make that happen for you.
Reminding us of our objective: You have a list of ICD-9 codes we are calling a “policy.” This list means something. Whether or not you can express the meaning in English, there is a scientific way of inferring its meaning. If you take a large set of patient records, and you find each record which has one or more codes on the policy list, then the set of patients you have found defines the meaning of the policy. For example, if the list is a complete set of ICD-9 diabetes diagnoses, then the patients it finds are, insofar as possible with ICD-9, all those with diabetes. Your objective is to re-write the policy list in ICD-10 so that, if the same set of patients were to be coded in ICD-10, application of the list to those records would find the same set of patients. This is not always possible, but the recipe I’m advocating generally keeps the discrepancy rate below 1%. Continue reading
Sue: Donna – just think in nine months the I-10 baby is gonna be born!
Donna: Well, at least we won’t have to decide on a name.
Sue: Right! But, you know how first-time parents go to classes to practice before the baby comes?
Donna: Yes… What are you getting at?
Sue: I’m saying that hospitals should be developing plans to have their coding professionals practice coding their medical records well before this baby’s due date.
Donna: I totally agree! There are so many benefits to practicing. Continue reading