June 10, 2011

Real GEMS: ICD-10 and MS-DRGs


Time is a funny thing. 

We often lament about the “speed” in which time flies and yet we can also be incredibly complacent about deadlines that seem really far away. 

The deadline for ICD-10-CM/PCS is one of those distant deadlines that are seen in both lights. On the one hand many professionals in the industry feel the timeframe till implementation is looming large and there is not enough time, and on the other a large contingent give ICD-10-CM/PCS very little thought, “it is just too soon.”  So what is the optimal “stance” on preparedness? 

Understanding the depth and breadth of the implementation is the easy part, as most know advisory bodies and vendors in our industry have published guides and lists of all the areas impacted and have given the 30,000-foot view of how to handle each issue. 

The hard part is putting together the “plan” and assigning the right “timeline” for completion. In order to place issues and tasks into perspective and place them into to the timetable correctly, we must have an in-depth understanding of the issue in relation to our facilities. So research and study of each component in the ICD-10-CM/PCS implementation plan is the point of this article and in particular the component of MS-DRGs and ICD-10-CM/PCS. 

CMS published the ICD-10-CM/PCS MS-DRG Version 28 Definitions Manual in February of this year to allow hospitals to understand the impact the implementation would have on case mix and the bottom line. The good news from CMS is that the draft of ICD-10 MS-DRGs is meant to replicate ICD-9-CM MS-DRGs. This means that when the coder correctly reports the documentation in the medical record that the MS-DRG for ICD-10-CM/PCS will be the same as it would have been for ICD-9-CM.  Or will it? 

Understanding the basis of the data and methodology used for the conversion project is imperative for every organization. There are so many variables that will occur from facility to facility that could and will impact the prophesized neutrality. Here is a brief list of these issues: 

  1. CMS tested the new mapping on MDC 6 the digestive MDC, and cited that five percent of mapping would require a clinical review. There could be a significant differences in other MDCs. CMS did identify that other translation issues were discovered where the assignment logic was especially complex, such as cardiovascular and orthopedic MS-DRGS. 
  2. The five percent of claims requiring review during the test did not account for service frequency, billed code volume or impact on dollars. When using GEMs to map the codes the percentage or dollars related to codes not cleanly placed into a DRG will likely be higher or lower than five percent. 
  3. When an ICD-10 code could be placed into more that one MS-DRG, MED PAR data were used in the process to select only one. Commercial health plan frequency data may have produced different results. 
  4. The improved code specificity in ICD-10-CM will eliminate some of the uncertainty that exists with ICD-9. This clarity may produce different MS-DRGs. 
  5. Although the total number of codes with complex mapping is small the total dollar and volume magnitude related to changes to CC/MCC are unknown. 

So knowledge is power and time is relative. CMS has made public its methods used for the conversion process, in a document called the ICD-10 MS-DRG Conversion Project: https://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp.  

CMS has been clear and upfront with its methodologies and problem-solving strategies. Unfortunately, as with most one-size- fits-all solutions, a portion of the “all” has problems with the fit. The vital factor in this discussion is that each organization must understand how the changes apply to them. 

One size will never fit all; the best way to be prepared is to fit your plan and timeline to your individual organization. 

About the Author 

Sandra L. Draper, RHIT, CCS, is the Director of HIM Practice for Precyse and is an experienced health information professional with over 20 years of HIM management experience. She has a record of consistent success in advancing health information management department's participation in revenue cycle performance, improving accounts receivables, and DNFB reduction through project management. 

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Read 168 times Updated on September 23, 2013