Updated on: September 23, 2013

Longitudinal Reporting and the Step Down/Step Up Debate

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Original story posted on: January 25, 2013

We’ve long believed that, when it comes to ICD-10, transactional processing will be less problematic strategically/intellectually than analytic processing.

Most healthcare providers (and payers) stopped building their own transaction processing systems years ago, opting for transaction processing systems from software (and now “cloud”) partners. It’s logical to assume (especially given the delay to 2014) that the software/cloud partners will deliver ICD-10-capable versions of their applications and their customers will have the opportunity to deploy these capabilities successfully to meet the mandated date.

Don’t get me wrong: Implementing a new system (HIS, EHR/EMR, HIM, Rev Cycle, etc.) is a major, costly, resource-intensive undertaking and implementation failures abound. I’m merely suggesting that not much thought goes into the strategy in scenarios where you’re either happy with, or unwilling to swap out, incumbent vendors (e.g. “upgrade” is the strategy).

Analytics strategy and, in particular, reporting on trends over time (known as “trending” or “longitudinal reporting”), however, require some deep thought to determine the most appropriate ICD-10 strategy.

There are two schools of thought, depending upon how much improvement you’re looking for in your ability to analyze the business, how much investment you’re willing to make in ICD-10 transition and ongoing operations, and your perspective on the efficacy of forward/backward translation. The diagram below illustrates the landscape for analytics strategy.

In theory, if an organization could take transactional history (encounters, claims, etc.) and “step up” the transactions from ICD-9 to ICD-10, and trend the translated (old, ICD-9) records with new (ICD-10) records, the increased specificity in ICD-10 should provide a dramatic improvement in the ability to analyze the business. However, this could be costly to achieve (and, in our opinion, impossible if the requirement includes the ability to step up ICD-9 procedure codes to ICD-10 PCS—we do believe that translating ICD-9 diagnosis codes to ICD-10 is possible, as described in a previous ICD-10 Monitor article).

Conversely, if an organization were to take new ICD-10 transactions and “step down” to ICD-9, the effort would be much smaller, but there would be no analytic benefit from the increased breadth and specificity in ICD-10 (certainly, the organization would be no worse off than the current ability to analyze the business).

The effort is much less, because of the general concept that translating from more to fewer is easier than fewer to more, and the availability of the reimbursement mappings. In fact, the percentage of one-to-one mappings in the ICD-10 to ICD-9 reimbursement mappings is more than 95 percent (for both CM and PCS), while the percentage of one-to-one mappings in the ICD-9 to ICD-10 GEMS mappings is less than 70 percent for CM and less than 15 percent for PCS.

We emphatically recommend to our clients (at least the sane ones!) that they strongly consider the “step down” approach for longitudinal reporting for at least the first 18 months to two years after the ICD-10 go-live date, unless they are absolutely required to produce a trend in ICD-10 for some external quality/compliance reporting, for a dominant trading partner, or where there is some significant clinical and/or financial benefit in a specific department or therapeutic area use case. Our rationale is that doing so will be more cost effective, and we don’t really believe in the “dramatic improvement” in analytics from the “step up” approach, due to the inability to reliably step up ICD-9 procedure codes to ICD-10 PCS.

As we’ve said to many a client debating longitudinal reporting strategy, if you’re going to step up, you’re going to need to translate procedure codes and, if you’re going to translate procedure codes from ICD-9 to ICD-10, you should always choose “left” because you will never be “right.”

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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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.