ICD-10 Ready: Translating Code Sets Essential to Mitigating Potential Reimbursement Changes

In April, Optum kicked off an 18-month effort to provide practical steps health care organizations can take to make their journey to ICD-10-CM/PCS successful, regardless how much—or how little—progress they’ve made toward implementing the new standard.

This month, we’re talking about code mapping. Before we get started, it’s helpful to recall that the reason the health system is undertaking this change is because ICD-9-CM is out of room. It’s five-place, numbers-only system cannot accommodate the required expansion of codes in many areas of health conditions.

By introducing a seven-place, alpha-numeric system, ICD-10-CM/PCS is better equipped to reflect the current state of medical practice and technology. By facilitating greater specificity to the type, location and severity of medical conditions, ICD-10-CM/PCS will also enable more powerful analytics to help improve quality of care and costs well into the future.

It is important to note that Congress requires CMS to ensure that the ICD-10-CM/PCS implementation be budget neutral. Many of the large health plans, hospital systems and large provider groups Optum works with have expressed the same goal.Laurine Johnson

Accordingly, for a period before and after the October 1, 2014 deadline, health care organizations will need to be able to translate between the ICD-9-CM and ICD-10-CM/PCS code sets, as payers analyze the data to determine the effect of the new coding system on payment processes. Diagnostic General Equivalence Mappings (GEMs) created by the National Center for Health Statistics and Procedural GEMs created by CMS will facilitate these translations.

While the GEMs are the authoritative source for translating between ICD-9-CM and ICD-10-CM/PCS, they are not a substitute to implementing ICD-10-CM/PCS. GEMs are severely limited, as you should expect from any attempt to map two systems as radically different from one another as ICD-9-CM and ICD-10-CM/PCS. As a result, attempts to map any given set of codes will deliver the following possibilities:

  • Exact match: The source and target codes are equivalent
  • Approximate match: The source  and target codes are similar
  • No match: The source code cannot be linked to any target in the other system
  • Combination: More than one code in the target system is required to satisfy the equivalent meaning in the source system

Given the sheer volume and specificity of ICD-10-CM/PCS codes, along with varying degrees of compatibility between the two code sets, physicians and hospitals will see changes in reimbursement. This is especially true where code or sequence changes alter the Diagnosis-related Group (DRG). In one case, a change in code sequence led to a 42 percent lower reimbursement. In another case, a new procedure code resulted in a 60 percent higher payment calculation.

Understanding which services may be affected and why will be critical to mitigating potential financial risk. Here are some recommendations to help you get a handle on your ICD-10-CM/PCS mapping processes:

  • Include both forward and backward GEMs in your mapping database
  • Include the reimbursement mappers with acknowledgement that these files only provide information for ICD-10-CM/PCS to ICD-9-CM
  • Perform mapping in context. For example, when mapping medical policies, utilize the GEMs, but also clinically review the results. If the medical policy is for a pediatric patient, then mapping results should be pediatric.
  • Remember, the GEMs provide a beginning, but not all of the information needed when mapping
  • GEM mapping results can be combined with other clinical sources (e.g., Medicare Code Edits (MCE)) for identification of gender, age and specific maternity based codes

Laurine Johnson


Leave a Reply