FEATURE sTORY Tools for Getting from ICD-9-CM to ICD-10-CM THE REAL DEAL, OR SMOKE AND MIRRORS? By Holly Louie, RN, PCS, CHBME, and Melody Muliak, MSHS, CRA, FAHRA, RCC, CPC, CPC-H W ith the fast-approaching ICD-10-CM implementation deadline of October 1, 2014, has come the proliferation of so-called translators, mapping programs, and crosswalks. Members of the billing and coding communities have been left asking, “Are these legitimate tools? Will they solve coding challenges by automating the coding process? Or will they just create new and additional challenges?” Regardless of the techniques used, coding compliance mandates that diagnosis codes must be assigned based on the medical record documentation, not simply on crosswalking tools. That requirement alone should serve as a guide to eliminate some of the “solutions” currently marketed. Because there are so few oneto one code matches, an ICD-9-Cm code cannot be converted to an ICD-10-Cm code without additional details from the medical record. Clarifications such as laterality, upper or lower, degree of trauma, and initial visit or subsequent visit are all embedded in the specificity of ICD-10-Cm code choices. even the best known mapping tool, Cms's own general equivalence mappings (gems), just provides the list of all possible ICD-10-Cm code choices for a specified ICD-9-Cm code. It does not designate which one is correct. simply choosing one from the list is clearly defined as a risk area in the “OIg Compliance guidance for Third-Party medical Billing Companies” – specifically, coding without documentation and/or assumptive coding. It is also the source of fraud concerns if payment is the result of a false representation of medical necessity. a significant aspect of the increased specificity in ICD-10-Cm is a discouragement on the use of nonspecific codes. It is true that many payors have long accepted and reimbursed unspecified diagnoses, and it is also true that ICD-9-Cm offers specificity that has not been reported by many providers. However, the payments for quality initiatives, outcome measures, disease reporting, treatment efficacy, and other incentives require much more information than currently exists. Be wary of products that simply replace existing unspecified codes with new unspecified codes. One specialty crosswalk listed a total of three ICD-10-Cm abdominal pain choices, while, in reality, there are eleven diagnosis codes for abdominal pain plus additional codes for abdominal tenderness. The suggestion to rely on the top 30 or 50 codes on a current superbill to establish your ICD-10-Cm code list is only as good as the current list. There will almost certainly be many more codes required, not only to include all the relevant choices, but also to incorporate the requirements to report multiple codes that describe a patient’s diagnoses. although the superbill approach may be a reasonable solution for some specialty practices, if done correctly it will probably be difficult to use for many providers. It is also important to remember this approach is supposed to represent the most common codes, and certainly does not include every possible patient scenario. Taking shortcuts is a real consideration to address with our clients. even the best tools can be misused, resulting in incorrect coding. Widespread anecdotal reports seem to indicate that when the physicians are given a pick list of all the code choices, they tend to select one or two of their favorites or choose a code from the top three. In other cases, the physicians have asked that only the “covered” codes be included in the pick list; this presents a significant compliance risk. It is now time to really focus on how coding will occur with our clients. The sheer number and strange appearance of the ICD-10-Cm codes can seem overwhelming to those who have not spent time learning and understanding the changes. This is especially true for situations where no professional coders or clinicians are assigning the diagnoses. spend some time educating clients on the coding changes, stress the similarities in coding conventions, and focus on the clinical benefits instead of the negative distractions. get involved in the selection of coding methodology that will be user friendly and result in accurate code designations. Do it now so that there is THe jOuRnal OF THe HealTHCaRe BIllIng anD managemenT assOCIaTIOn 19
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