When researchers looked at how current pediatric diagnosis codes will be mapped forward to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), codes in October 2015, they found that more than 1 in 4 of them could be tangled in difficulty.
Rachel Caskey, MD, from the Department of Pediatrics and the Department of Internal Medicine at the University of Illinois at Chicago, and colleagues analyzed all Illinois Medicaid International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), data for 2010 for all patients identified as primary care patients of the University of Illinois system as of April 2011.
They found that 26% of the 2708 pediatric diagnosis codes were convoluted, meaning information is overlapping, inconsistent, or lost in the transition from the current codes to the new codes. That represents 21% of Illinois Medicaid pediatric patient visits and 16% of reimbursement. Dr. Caskey and colleagues present their results in an article published online June 2 in Pediatrics.
The authors looked at how the ICD-9 codes would translate and put them into 5 categories: identity (where the codes are equivalent), class to subclass (1 code goes to multiple ICD-10 codes), subclass to class (multiple codes go to 1 ICD-10 code), no transition (no mapping to ICD-10), and convoluted (a complex mapping of ICD-9 to ICD-10.)
The first 4 categories include codes in which the transition is straightforward. The “convoluted codes have complex mappings, making the transition difficult,” the authors note.
Senior author Andrew Boyd, MD, assistant professor in the Department of Biomedical and Health Information Sciences in the College of Applied Health Sciences at the University of Illinois at Chicago, told Medscape Medical News that the convoluted codes are easily identified. “You just need the clinician, the coder, [and] the administrator to figure out, ‘is the complexity relevant to our practice?’ ”
He recommends that physicians use a free online conversion tool to plug in the codes they use most often and see how they map forward.
“You would hate to submit a claim and be denied because of the way the government maps,” he said. Information inconsistency can happen at the point of the physician, the hospital, or the insurance companies. “All of them have spent significant time and resources to get this transition right, but we’re talking about 80,000 codes over 100,000 mapping translations. They all have to work seamlessly to make sure everyone gets paid,” Dr. Boyd said.
Among examples of how the codes translate are that the ICD-10 code for a twin live vaginal birth is the mapped-forward version of 3 ICD-9 codes used for both stillborn and live twin vaginal births, and that the ICD-9 code for malignant essential hypertension maps forward to essential primary hypertension under ICD-10, losing the word “malignant,” which is clinically distinct from nonmalignant essential hypertension.
In the case of the latter example, “If you put in [ICD-9 code] 401.0, it maps to essential primary hypertension. The information loss is the fact that it’s malignant, that it’s extremely high, the fact that it can cause organ damage, making it a much more critical case than just saying you have hypertension,” Dr. Boyd said. “From a clinician’s point of view, you are losing critical information during this transition. You need to be aware of it, especially if you’re trying to get urgent or expensive care.”
The authors note that diagnosis codes that involve information loss, overlapping categories, and inconsistent information represented 8% of Medicaid pediatric reimbursement.
That does not mean the authors predict an 8% loss in reimbursements when the codes change. “We’re saying that 8% is at the highest risk for challenge going forward,” Dr. Boyd said.
“Many pediatric practices function on a thin financial margin in which 3% to 5% of codes resulting in billing errors could have a significant financial impact. Sufficient planning to mitigate this challenge and prepare is necessary,” the authors said.
In an accompanying editorial, Alexander G. Fiks, MD, MSCE, and Robert W. Grundmeier, MD, from the Center for Biomedical Informatics at the Children’s Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, agree. They urge health systems to use the newly published data to troubleshoot before the codes kick in.
“As mentioned by the authors, appropriate ICD-10-CM training should be provided to billers, staff, clinicians, and others using the data. In addition, we recommend that all health systems generate reports of their most frequent diagnoses to determine which may be subject to errors, based on this analysis by Caskey and their own review,” they write.
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Originally published on: Medscape
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Pingback: Transition to ICD-10 Convoluted for 1 in 4 Pediatric Codes | scrubs and suits
with the implementation of so many new codes, may be we have lot of problems during transition and one of them is discussed in this article about padiatric codes….good info to be careful with the new codes in future.
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