What CEOs and CFOs Need to Know About the ICD-10 Transition

What is the difference between ICD-9-CM and ICD-10-CM? It’s a huge one, and it’s one that requires a marriage between critical thinking skills and the thinking that goes into medical decision making. In other words, the clinical staff will need hands-on efforts to master the new scenario which requires a level of specificity never required by Medicare or any other entity.

There are some who think that their computer systems and certification of coders will be enough to have a successful revenue cycle under the new rules. Also, we hear from some of our clients that they have software that will help them make the “transition”.

The first thing that administrators, financial folks and coders need to know is that there is no one-to-one match between ICD-9-CM and ICD-10-CM. This means that the word “transition” needs to come out of the vocabulary and the words like “new concept/new paradigm” must enter it.  Since there is no one-to-one correspondence between the two in either diagnosis codes or procedure codes, the approach to implementation has to be radically different.

While coding has existed for a hundred years it wasn’t until the 80’s that coding was associated with reimbursement through the Diagnostic Related Groups (DRGs).  CMS then determined that DRGs had to be related to the severity of the patient, each of whom might have a lesser or greater severity within the same DRG and thus we were given MS-DRGs.  Finally, the idea of doing diagnostic related groups in the outpatient clinics came.  So we had Ambulatory Patient Classification which also began the process of changing reimbursement of outpatient procedures.   Through all of these iterations of coding and the accompanying intensifying of clinical documentation, our firm has always found an enormous gap between clinical decision making and the terminology to support those.

The clinicians who believe that they are using the correct terminology and the coders who interact with physicians both try to convince them that what they describe in their clinical documentation doesn’t support either the procedure or visit level that they indicate. Of course, this is frustrating for the physicians and makes for real tension when they are constantly asked questions about their diagnosis (terminology) rather than their clinical judgment.

Let’s look at why there is no real matchup between coding schemes:

  • ICD-10 includes new concepts that were not present in ICD-9.
  • ICD-10 uses new codes for conditions never represented in ICD-9.
  • Certain conditions that required multiple codes in ICD-9 now are represented by one classification in ICD-10.
  • Conditions requiring many codes in ICD-10 may have been represented by one code in ICD-9.

Perhaps one could say that the difference between them is the difference between viewing an object in one dimension vs. three dimensions.  The specificity that drives ICD-10-CM/PCS doesn’t change clinical decision making but it reorders how a visit or procedure are to be described and then finally coded.

On the coding end, books and software are only part of the solution. The most important part is in-depth understanding of what is happening on the clinical level joined with critical thinking skills. This is not only an issue for the HMIS department or the billers, but has to move up through the organization to the very top. The new coding/clinical documentation requirements also demand a cultural change and an internalization for there to be successful outcomes.

Procedure coding in ICD-10-PCS means not just selecting from a book (as in ICD-9) but rather having them built by coders utilizing the clinical documentation, an understanding of the construct of ICD-10-CM, a complete  grasp of clinical content, and the ability to bring critical thinking skills to the effort.

In a recent survey we found that while there was awareness on the part of the executive team, many still thought that the encoder would be the problem solver in cross walking ICD-9-CM procedure codes to ICD-10-PCS.  For those who think that signing off on the purchase order for the new encoder is the answer that solves the problem, they are not correct because the encoders can’t do this.

Administrators, including the top clinical staff have to understand that the following pertains under the new ICD-10-CM/PCS code set and is supported by our company’s study and CMS’s review:

When CMS did their mapping conversion which mapped ICD-10- back to ICD-9, it resulted in patients being assigned to a different MS-DRG with a bias to toward the lower pay MS-DRGs.

The medical staffs are going to find that physicians reimbursed for their services based on CPT procedure coding are not always aware that the diagnostic code must support the procedure or else medical necessity or the lack thereof prevails.

Our recent surveys point to an ever growing wisdom among administrators that there is a cultural change and a reordering that can bring administration and medical staff together as both face the challenge together.

Cathy Idema, BSN, MPH, FAAHCC
Mary Lou Laugh, B.S., RHIT,CCP, CCP-H and Certified ICD-10-Trainer
HSMN (Health Systems Management Network)