August 24, 2011

Mom and Pop Mappers

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Editor’s Note: On a recent Talk-Ten-Tuesday podcast, the ever-popular Billy K. Richburg
described the perils of mapping. His segment is transcribed below.

 

I’ve been accused of being somewhat cynical when it comes to anything the federal and state governments do, and I’ll confess there’s considerable truth in that. But today I want to talk about the kinds of things non-government payers do – apparently with the sole purpose of irritating the rest of us.

ICD-10 has all sorts of advantages, one of which is that it’s the same everywhere, thanks to the feds. “Mom and Pop’s Health” out of some backwater burg in rural America can’t make up their own codes unless they really thrive on violating the HIPAA Transaction Rule, which is illegal.

But what about the things related to ICD-10 not addressed by the Transaction Rule? How about a specific example: crosswalks!

Crosswalks are a critical component of our transition to ICD-10, but as incomprehensible as it seems, there isn’t a single mandated crosswalk. Yes, CMS publishes GEMs, but right on its website they say the mappings can be used to develop “alternative mapping systems” for specific purposes. In other words, “Mom and Pop’s Health” can make up their own mapping.

So how exactly is this a problem?

For most hospitals, larger clinic groups and the like, it probably means very little. But using multiple mapping systems would make it impossible to reliably model ICD-9 and ICD-10 versions of the same claims to see how DRG grouping would compare, for example. “Mom and Pop’s Health” claims might map right one time and wrong the next.

But the greatest risk is to smaller providers – small clinics, small home health agencies, mid-level independent practitioners such as therapists and nutritionists – that think they cannot afford to have their claims professionally coded, so they instead depend on crosswalks to simulate proper coding. For those people, multiple crosswalks may be their ultimate nightmare: they’ll never know how they’re going to be paid. It’s bad enough to use one flawed system (like GEMs), but it’s a bona fide disaster-in-the-making to try to use several of them simultaneously.

So no matter who you are, no matter how large or small your practice or your organization, do not think for a moment about using GEMs or any “how gullible are you?” alternatives to code claims. It’s just not worth it.

About the Author

Billy K. Richburg, MS, FHFMA, is HFMA-certified in accounting and finance, patient accounting and managed care. Bill graduated from the University of Alaska in Anchorage and earned his MS in healthcare administration from Trinity University in San Antonio, Texas. During a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO and CIO in hospitals ranging from 75 beds to more than 300 beds, and in home health agencies, DME stores and a home infusion company. Bill is a board member of the Lone Star Chapter of the HFMA and is director of government programs for the Revenue Cycle Management business segment of MedAssets Inc. His office is in Plano, Texas.

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Read 80 times Updated on September 23, 2013
Billy Richburg, M.S., FHFMA

Billy K. Richburg, MS, FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the University of Alaska, Anchorage and earned his MS in Health Care Administration from Trinity University, San Antonio, Tex. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Senior Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.