January 8, 2013

Code Set Competency: Six Steps to a Successful Transition to ICD-10 - Pt. 1

By Carol Spencer and Mike Younkman

EDITOR’S NOTE: This is the first in a two-part series

To be successful using ICD-10, payers, providers and vendors should follow six simple steps for management of code transition from ICD-9. It is critical that each organization apply a common mapping consistently in order to meet the compliance date.

Industry goals include compliance and business neutrality, as well as more accurate and detailed clinical and quality reporting, improvements to patient safety, better tracking of patient outcomes, improvements to the accuracy of claims processing, prevention of fraud and abuse, and the availability of richer sources of data for clinical research.

Here are the first three of those aforementioned six steps:

1. Design a mapping tool that is specific to the business needs of your organization.
To ensure consistency and transparency, each organization should select a mapping software application as the standard mapping application for all remediation work. Remediation is the process of translation from ICD-9 to ICD-10 for the hundreds of thousands of applicable business rules and codes. One such software application, HLI’s LEAP I-10, is embedded with the Centers for Medicare & Medicaid Services (CMS) General Equivalency Mappings (GEMs). From the GEMs file, the WellPoint Reference Map (WRM) was designed to meet the specific needs of businesses, and it is included in LEAP I10.

The WRM, simply put, is the GEMs offered with additional attributes such as laterality, chapter changes or the exclusion of notes. In addition, the WRM routinely is updated to include purpose-built maps (PBMs) – map changes that meet enterprise-wide business needs. This customized GEMs file allows clients to meet the unique and varied business needs of benefits, clinical, and pricing arenas, as well as those of other key business segments.

Each remediation team begins its map translation effort with the WRM as a primary source. Once the remediation work is complete, the WRM is moved to a reference data platform to allow for auto-configuration of all business rules. Auto-configuration allows for automated updates by replacing the hundreds of thousands of ICD-9 codes in business rules with their equivalent clinical and business ICD-10 codes, the goal being neutrality.

If a benefit is approved on an ICD-9 code, then the plan is that same benefit will be approved with the ICD-10 codes.

2. Select your highest-impact business units for initial mapping efforts.
The decision to select two initial claims platforms was based on large memberships and the fact that they are long-term target platforms. One of the claims platforms also had external dependencies, representing an additional reason. We also started with a third business unit, the clinical system, due to its direct impact on members engaged in critical medical services. Any issue could create friction, which must be avoided.

3. Include credentialed clinical coding experts in projects related to mapping.
The clinical coder skill set that a HIM coding consultant expert recently brought to a team of insurance experts during the process of remediation resulted in synergies that would not have been attained otherwise.

As a result of these remediation meetings, not only were insights related to mapping identified, but the team identified process and technical opportunities as well. For example, a rule designed to process a behavioral benefit for sexual dysfunction was evaluated by the remediation team. The sexual dysfunction codes are classified in the ICD-9 Mental Health chapter, and an unspecified sexual dysfunction code was identified in the Signs and Symptoms chapter.

To ensure correct processing and neutrality, this symptom code was added to the benefit rule to retain the business and clinical context. In a second example, it was determined by the HIM coding expert that there was an omission in annual code updates, specifically coming in the form of a missed update of the 249.xx diabetes codes introduced a few years ago. After much discussion, we arrived at a decision on how to remediate missed ICD-9 codes during the act of remediating the ICD-10 codes.

Another example of insights provided with the HIM coding expert included as part of the team is identifying potential computer limitations with field length. It was determined that one ICD-10 code was truncated. This resulted in an ICD-9 and an ICD-10 code reading the same as an alphanumeric value, but different as descriptors: V723 in ICD-9 is “gynecological exam,” which is truncated from its fifth digit, and V723 in ICD-10 is “unspecified occupant of bus injured in collision with two- or three-wheeled motor vehicle in non-traffic accident,” which is truncated from the sixth and seventh digits. In summary, process improvements, the annual code update, technical improvements and field limitation revisions are a result of synergy generated by a team effort.

The primary goal of the HIM coding expert is to assist the remediation team with forming accurate and appropriate ICD-9-to-ICD-10 map translations. In other words, the intent is to review all maps and identify any ICD-10 map(s) that do not match the clinical and business context of the business rule. Once such a map is not accepted, it becomes known as a derivation. For example, consider that a derivation is identified for case management. It is determined that the “traumatic subarachnoid hemorrhage with death” map needed to be disabled in order to avoid a case manager making contact with a surviving family member.

Another example is the “unspecified angina” code in ICD-9 that typically denies a benefit; we determined that for the business rule, to avoid denying the benefit for coronary artery disease, the ICD-10 combination code (“coronary artery disease with angina”) needed to be disabled. The derivations are documented in the LEAP I10 tool and laid out in an Excel spreadsheet called a Business Configuration Inventory (BCI). Any derivation from the WRM map is documented to differentiate the codes for manual configuration as well as for the purposes of control and traceability.

Following the key steps plus the three additional ones in the second part of this series will help focus your organization’s efforts on areas that will support these key goals.

About the Authors

Carol Spencer is the program director for WellPoint’s CodeSet Competency Center. Mike Younkman is the director of WellPoint’s ICD-10 execution.

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Click here to read Part 2 of this series

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.