Payers (2)

If you want to see an ICD-10 program manager or business lead squirm, bring up the topic of translation from ICD-9 to ICD-10. The ICD-10 to ICD-9 translation topic doesn’t produce nearly the same level of angst due to the availability of the more one-to-one-laden reimbursement mappings.

Many of our clients are “pulling an ostrich” (planting their heads deeply in the sand and ignoring the world) when it comes to the concept of translation from ICD-9 to ICD-10, and hoping that they can avoid it entirely. Many payers and providers so far have chosen not to translate, opting for a “step back” approach to analytics (i.e., after Oct. 1, 2013, they will translate new ICD-10 claims/encounters to ICD-9 using the reimbursement mappings, and cross-correlate legacy data to the step-backed ICD-10 codes for trending).

This approach will work for many companies and for many types of analytics. However, the intent and approach to the reimbursement maps may not be clinically relevant for every purpose, and we believe that for some purposes (and for some companies looking to gain benefits from the increased specificity in ICD-10), translation from ICD-9 to ICD-10 will be a requirement, especially for diagnosis codes. Consider that for some regulatory, quality and trading partner analytics, trending in ICD-9 with stepped-back ICD-10 codes will not be acceptable.

But maybe translation from ICD-9 to ICD-10 is not so bad.

In our body of work providing analysis and translation services for clients, we’ve found that translation from ICD-9-CM to ICD-10-CM is achievable with very little manual intervention and a high degree of automation. The numbers might surprise you.

There are approximately 14,000 ICD-9-CM codes listed in the GEMS 9-to-10 maps that map out to one or more ICD-10-CM codes. Of these mapped codes:

  • Approximately 78 percent are compatible with “one-to-one” mappings (i.e. the GEMS maps contain one and only one correlating ICD-10-CM code to the ICD-9-CM code.) Of these, 25 percent are exact while 53 percent are approximate.
  • Approximately 17.5 percent translate as “one-to-many” approximate mappings (i.e. the GEMS maps contain more than one correlating ICD-10-CM code to the ICD-9-CM code, and GEMS specifies that the mappings are all approximate: any of the ICD-10-CM codes are a potential map).
  • Approximately 4.5 percent are “one-to-many” combination mappings (i.e. the GEMS maps contain multiple ICD-10-CM codes for the ICD-9-CM code, with GEMS specifying that the mapping is of the combination type. There can be one or more scenarios, with potentially multiple choice lists per scenario).

It’s the 22 percent of the codes that are one-to-many (approximate or in combination) that are problematic in that they cannot be translated automatically using the base GEMS maps. However, with some analysis a high percentage of these mappings can be simplified. My company has invested in a value-added mapping called the “HighPoint GEMS” to get to a higher percentage of mappings that can be translated automatically.

  • Of the “one-to-many” approximate mappings, for roughly 70 percent of the codes it is fairly straightforward to pick the most generic mappings (i.e. where there are some very specific codes and one that is much less specific, using “other” or “unspecified”) and arrive at a one-to-one approximate mapping.
  • Of the “one-to-many” combination mappings, for roughly 47 percent of these codes there is only one scenario and the number of ICD-10-CM codes is equal to the number of choices, making it fairly straightforward to translate.


The net of it is that approximately 92 percent of the mapped codes can be translated automatically from ICD-9-CM to ICD-10-CM.


That’s not so bad.


About the Author

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

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“We need to talk.”

Those words generally tend to make people nervous, but we really do need to talk about the move to ICD-10-CM and ICD-10-PCS (hereafter referred to as the ICD-10 code sets). The more we talk, the more we all can contribute toward mitigating the anxiety associated with this massive and important change to how medical diagnoses and inpatient hospital procedures will be coded and reported. If payers, providers, trading partners, medical societies and the other various components of the entire healthcare industry work together to foster open, ongoing communication about progress toward preparing for the Oct. 1, 2013 implementation date for the ICD-10 code sets, it will help assure a smoother and more seamless transition.

Not surprisingly, the Centers for Medicare & Medicaid Services (CMS) outreach efforts have demonstrated that knowledge of the ICD-10 code sets is limited in smaller organizations and noticeably broader among larger provider, payer and vendor organizations. CMS found that smaller healthcare providers are taking a “wait-and-see” attitude, expecting CMS, vendors, larger providers and payers to inform them about the transition and what to do. So clearly we do have some talking to do in the healthcare industry.

For some time now, CMS and other payer organizations have been communicating more general information about the ICD-10 code sets through provider outreach and educational programs. However, it would behoove payers and providers to talk specifically about how they can work together to assure that appropriate processing of claims on the effective date and beyond will achieve consistent and predictable payment results. This kind of partnership would provide opportunities to communicate about:

Whether each of the partnering entities intends to fully remediate/convert all systems to process the ICD-10 code sets versus implementing a temporary internal mapping solution that would forward- and/or backwards-map ICD-9 and ICD-10 codes for some applications;
How mapping decisions and rationale will be communicated to impacted trading partners; and
Potential contract issues or conflicts in areas in which payments currently are driven by ICD-9-CM diagnosis and/or procedure codes.

It will be very important for payers and providers to communicate clearly about how claims with dates of service of Oct. 1, 2013 and later will be processed and paid. If the ICD-10 codes submitted on a claim can be mapped back to ICD-9 codes for internal processing, the payer will need to be able to communicate the payment decisions back to providers and determine how to make business rules regarding mapping decisions fully transparent and available for external review.

Payers, providers, vendors and other HIPAA-covered entities impacted by the transition to the ICD-10 code sets can contribute to fostering communication and awareness in a variety of ways, namely by following these guidelines:

    • Know where the official ICD-10 resources are (www.cms/gov/ICD10), and pass the word.
    • Attend as many ICD-10 educational sessions as possible.
    • Volunteer to share best practices and lessons learned at the local, state or national level.
    • Join ICD-10 strategy and implementation workgroups sponsored by industry leaders such as America’s Health Insurance Plans (AHIP) and the Workgroup for Electronic Data Interchange (WEDI).
    • Reach out for help if you are behind in your impact assessment and planning efforts.
    • Complete industry readiness surveys when issued by CMS.

We are all in this transition to ICD-10 together, and true collaboration is the key to success.  

About the Author

Nancy Engel, RHIT, CCS, has more than 35 years of experience in the health information management (HIM) profession. Nancy currently serves as Manager of Facility Reimbursement Coding Principles for United Healthcare, located in Edina, MN.  In this role, Nancy has responsibility for ensuring the accurate application of facility coding and reimbursement practices across one of the largest health insurance plans in the U.S.  Her previous positions include assistant director of HIM for a large university hospital, HIM consultant and coding manager.

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