Medicaid ICD-10 Workarounds in Four States Worry Providers

On Oct. 1, Medicaid programs in four states will not be fully converting from the ICD-9 to the ICD-10 coding system, as nearly everyone else is federally mandated to do. Instead, they have received CMS approval to take incoming claims coded in the new ICD-10 system, convert them into ICD-9 codes, and use the older system to calculate payments to healthcare providers.

Provider groups and health IT experts warn there are risks of payment delays and snafus associated with this patchwork approach.

All HIPAA-covered entities, including hospitals, office-based physicians, claims clearinghouses and health plans must comply with the federal mandate for full ICD-10 conversion on Oct. 1. But the CMS has signed off on a “crosswalk” technique to translate ICD-10 codes into ICD-9 codes and keep using the older codes as a workaround for Medicaid fee-for-service programs in California, Louisiana, Maryland and Montana. The claims processing systems in those four states are unable to perform payment calculations using the new ICD-10 codes.

CMS spokesman Jibril Boykin confirmed his agency approved the crosswalk approach in the four states. “We have worked closely with each state to understand how they will mitigate any issues that may arise and minimize impact on the accuracy and timeliness of provider payments.”

While the CMS has approved the crosswalks, Boykin said it is “not as a long-term approach.” Asked if there were time limits, he said “it varies on a state-by-state basis.”

California hospitals are not happy about Medi-Cal’s plan. “We do continue to have some concerns about the use of the crosswalk approach and we’ll be raising these concerns during a stakeholder meeting next week,” said Jan Emerson-Shea, spokeswoman for the California Hospital Association.

Robert Tennant, senior policy adviser at the Medical Group Management Association, which has opposed the federal push to require ICD-10 conversion, expressed concern that such important information about state Medicaid programs and ICD-10 readiness is surfacing less than a month before the compliance date. “That’s exactly what we feared would happen,” he said. “We’ve asked for the readiness levels for Medicaid for five years and we didn’t get an answer from the CMS. What it reminds me of, and I hate to say it, is the futility of using this code set. If they’re going to convert it to (ICD-) 9, why did we do this?”

Health IT consultant Stanley Nachimson said crosswalking from ICD-10 to ICD-9 codes has its pitfalls. “It’s certainly not the preferable way,” he said. “There are some ICD-10 codes that do not crosswalk back to ICD-9 codes. I don’t think it’s a good solution. In my opinion, it’s taking the easy way out and not getting to the right answers. They should have gotten their machines ready. They could have talked with some other states and seen how they’ve done it.”

The four state Medicaid programs may not be the only payers using the crosswalk technique, said Holley Louie, president-elect of the Healthcare Billing and Management Association. “We’ve heard from some of the smaller commercial plans that they’re going to do the same thing.”

Representatives of Medicaid programs in Louisiana and Montana could not be reached for comment by deadline. A Maryland Medicaid spokesman said his state took this approach because its “system architecture does not allow for ICD-10 native compliance,” adding that the state will use the crosswalk until it has migrated to a new system.

In California, Medi-Cal’s crosswalk wasn’t a quick fix at the last minute. According to California Department of Health Care Services spokesman Adam Weintraub, in March 2010 California approved a six-year, $1.6 billion contract with Xerox Health Systems to upgrade the software for its Medicaid management information system. A proposal to upgrade to ICD-10 and use a coding crosswalk were in Xerox’s response to California’s request for proposals bid from the beginning.

The CMS had signed off on California’s use of a crosswalk when it approved funding for the upgrade project, Weintraub said. Xerox began work on the ICD-10 enhancement in November 2010, he said. It was implemented in September 2014 after nine months of extensive system testing, including external testing with Medi-Cal providers, Weintraub said. It’s continuing those tests now “to verify equivalency of claims adjudication for ICD-9 coded claims to ICD-10 coded claims for the same medical scenario.”

There is a 95% pass rate on claims in this latest round of testing, Weintraub said.

In an FAQ page on the Medi-Cal website, the state agency said its crosswalk “will only be used temporarily.”

“California is working on a (claims processing) system replacement effort which, upon implementation, will process natively using ICD-10,” Weintraub said. “As an interim solution, Medi-Cal implemented ICD-10 on our legacy system utilizing a crosswalk in order to reduce the cost and system changes to an aging system that is being replaced. … This approach allowed California to minimize risks and impact to our providers by reducing the chances for payment variances between ICD-9 and ICD-10.”

Weintraub said only the providers’ originally submitted ICD-10 codes, not crosswalk-converted codes, would be used and grouped to create hospital diagnosis-related groups.

But Medi-Cal won’t publish its composite crosswalk so providers can see its logic, the agency said, “since there is already a process for the appeal” over disputes regarding the amount paid and the amount submitted. Keeping a crosswalk private is “consistent with industry standards for any payer system,” Weintraub said.

Nachimson said the CMS has been keeping tabs on the state Medicaid programs, in part because Medicaid management information systems are largely federally funded, with a 90% federal match for system design and development and 75% for operations. But the CMS’ Medicaid office has been “very quiet” about states’ readiness levels, Nachimson said. “The response from CMS was they did not feel comfortable disclosing the information that the states were reporting.”

The four crosswalk states have nearly 15 million Medicaid beneficiaries, according to CMS data, but probably fewer than 3 million of those beneficiaries could have their Medicaid claims pass though the crosswalks. That’s because most Medicaid beneficiaries, particularly in California, are covered through capitated Medicaid managed-care plans. Capitated plans don’t bill for each service.

More than 12.5 million Californians are Medi-Cal enrollees, but roughly 80% of them are in managed-care plans, according to Weintraub. That still leaves about 2.2 million Californians under traditional fee-for-service Medicaid, he said. Bills for those patients will fall under the Medi-Cal payment scheme.

A crosswalk is simply a text file on a computer, with ICD-9 codes in one column and corresponding ICD-10 codes in another, explained Dr. Andrew Boyd, assistant professor in biomedical and health information sciences at the University of Illinois at Chicago. Crosswalks can map codes in either direction, from ICD-10 to ICD-9, or the reverse.

But Boyd cautions about the pitfalls healthcare organizations will face during the transition period dealing with crosswalks from ICD-9 to ICD-10. The risks include compromised data quality from “convoluted codes” that don’t map to similar concepts in moving from one code set to another, as well as hits to providers’ bottom lines from delayed or rejected claims due to cross-coding issues.

Medi-Cal officials, in a posting online, said they developed their own crosswalk starting with publicly available lists called the General Equivalence Mappings, or GEMs (PDF). Those mappings were developed by the CMS and the Centers for Disease Control and Prevention with input from the American Hospital Association and the American Health Information Management Association. There are four sets of GEMs for the ICD-9 to ICD-10 conversion. Combined, they allow mapping for both ICD diagnostic and procedural codes in both directions.

In addition, the CMS developed a set of publicly available reimbursement mappings that link payments to the ICD-10 codes. In developing its crosswalk, Medi-Cal used these public mappings, but didn’t stop there. Medi-Cal took its crosswalk behind closed doors by giving it a tweak, “modifying the (public) mappings to align with existing Medi-Cal policy,” the state agency said, in a FAQ about ICD-10 on its website. “Claims that are submitted with ICD-10 starting Oct. 1, 2015, will run against this crosswalk in order to identify the appropriate ICD-9 code that will be used to process the claim,” Medi-Cal explained.

Medi-Cal’s refusal to publish its crosswalk methodology bothers some experts, because any flaws the state might have in its methodology or technology will be hidden behind the veil of its propriety crosswalk and will work against providers in claims disputes. “They’re saying if we make a mistake, at least you can appeal,” MGMA’s Tennant said. “Thanks so much.”

“My biggest concern is delay of payment for hospitals and physician groups, because cross-mapping could result in a cash flow crunch on already narrow margin groups,” the University of Illinois’ Boyd said. “You submit a claim and you appeal. That process takes time. It also takes up staff time. It has an impact on your cash.”

Meanwhile, Boyd said, “You still have to pay your rent, and your staff.”

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Photo courtesy of: Modern Healthcare

Originally published on: Modern Healthcare