ICD-10: A Master Data Problem
ICD-10: A Master Data ProblemW H I T E PA P E R
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White PaperTable of ContentsICD-10 is Mandated at the Worst Possible Time . . . . . . . . . . . . . . . . . . . . . 2The Inherent Complexities of ICD-10 Inhibit Proper Adoption . . . . . . . . . . . 3GEMS and Reimbursement Mappings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Implementation Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Different Rules for Different Purposes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Software Vendor Crosswalk Variations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Trending and Analytics with Historical Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Time and Cost will be a Formidable Adversary to Any Well-Intentioned Plan to RemediateEverything. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7The Solution: Master Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ICD-10: A Master Data Problem1
ICD-10 is Mandated at the Worst Possible TimeThe common approach to ICD-10compliance leaves many unsolvedchallenges. Is a master data solution theanswer?Savvy health care organizations are already starting to conduct their ICD-10 assessments, wellahead of the federal government’s new deadline of October 1, 2014, for implementing the newcoding system while also meeting new requirements introduced by the Patient Protection andAffordable Care Act (healthcare reform) and meaningful use requirements established by theHITECH Act. That’s a lot of business process disruption and IT work to be handled in a short periodof time. Many payers and providers don’t have the resources or the time to get it all done.Organizations need to think of efficient, durable approaches that can facilitate cost-effectivecompliance for the pile of mandates occurring over the next several years. For ICD-10 in particular,adopting a master data management (MDM) approach can resolve several challenges withimplementation of this new code set by establishing a single, centralized, controlled point ofreference for disease and procedure codes, rules, mappings, and translations that can be applieduniformly to all applications. It can also help organizations position themselves for subsequentrevisions of the ICD codes.2
White PaperThe Inherent Complexities of ICD-10 InhibitProper AdoptionICD-10 vastly increases the number and complexity of disease and procedure codes over ICD-9,the previous standard enacted in 1977. ICD-10 contains 141,060 codes, a 712% increase overthe 19,817 codes in ICD-9. Given the dramatic increase in codes from ICD-9 to ICD-10, onemight expect that there would be a one-to-many relationship between ICD-9 and ICD-10, whichwould make it fairly straightforward to link across the code sets. However, the relationship is manyto-many, as illustrated by the example of diabetes mellitus.As expected, one ICD-9 code can relate to many ICD-10 codes, as displayed in Figure 1.Figure 1ICD-10: A Master Data Problem3
But, unexpectedly, one ICD-10 code can also relate to many ICD-9 codes, as displayed in Figure 2.Figure 2GEMS and Reimbursement MappingsTo help facilitate care and commerce, the government has invested in providing mappingsbetween ICD-9 and ICD-10. There are two such mappings endorsed by CMS: the GEMS maps (forboth ICD-9 to ICD-10 and ICD-10 to ICD-9) and the Reimbursement maps (for ICD-10 to ICD-9only). GEMS, which stands for General Equivalency Maps, establishes links amongst codes thatare generally equivalent in each code set. The Reimbursement maps were created after the GEMSmaps and are more specific, identifying the top candidate mappings from within GEMS.Some statistics may illuminate the challenges inherent in linking across the code sets.In the GEMS maps for procedures from ICD-9 to ICD-10: There are 445 instances where a single ICD-9 code can map to more than 50 ICD-10 codes. There are 210 instances where a single ICD-9 can map to more than 100 ICD-10 codes.In the GEMS maps from ICD-10 to ICD-9: There are 6,821 instances in the mappings for diseases where a single ICD-10 code canmap to more than one ICD-9 code. There are 6,740 instances in the mappings for procedures where a single ICD-10 code canmap to more than one ICD-9 code.In the Reimbursement maps from ICD-10 to ICD-9: There are 3,334 instances in the mappings for diseases where a single ICD-10 code canmap to more than one ICD-9 code. There are 2,300 instances in the mappings for procedures where a single ICD-10 code canmap to more than one ICD-9 code.The depth and breadth of ICD-10 and the increased specificity of diseases and procedures createmany opportunities for payers and providers to promote better health while constraining costs.Yet, the many-to-many nature of the relationships creates challenges for healthcare payers andproviders in processing transactions, analyzing their businesses, and maintaining compliance withregulatory requirements.4
White PaperImplementation ChallengesDifferent Rules for Different PurposesWhile CMS has tried to create clarity with GEMS and Reimbursement mappings, the resultsaren’t encouraging: GEMS ICD-10 to ICD-9 mappings have 5.47% exact matches for diseasesand only .10% exact matches for procedures; GEMS ICD-9 to ICD-10 mappings have 23.76%exact matches for diseases and no exact matches for procedures. With so few exact matches,organizations will need to define their own business rules for specific trading partners andbusiness functions that add value to or override the government mappings.For example, consider the ICD-10 code E10311: Type 1 diabetes mellitus with unspecifieddiabetic retinopathy with macular edema.Figure 3According to GEMS mappings and Reimbursement mappings, this ICD-10 code can map to: ICD-9 250.51: Diabetes with ophthalmic manifestations, type I [juvenile type], not statedas uncontrolled ICD-9 362.01: Background diabetic retinopathy ICD-9 362.07: Diabetic macular edemaConsider a situation where a few trading partners are dominant in a given market and may bestrong enough to dictate policy. For example, Hospital A might dictate to Payer A that the propermapping for them is to 362.01 and Hospital B might dictate to Payer A that the proper mappingfor them is 362.07. In this situation, an organization needs to be able to override the governmentmappings.Figure 4ICD-10: A Master Data Problem5
Additionally, the mappings might be overriden differently by business process or function. Tounderstand this point, consider the ICD-9 code 88.71: Diagnostic ultrasound of head and neck.Figure 5According to GEMS, this ICD-9 code can map to: ICD-10 BW4FZZZ: Ultrasonography of Neck ICD-10 B040ZZZ: Ultrasonography of Brain ICD-10 BH4CZZZ: Ultrasonography of Head and NeckFor financial purposes, assuming that there is significant differentiation in cost and reimbursementbetween an ultrasound of the brain and an ultrasound of the neck, the default mapping wouldlikely be to ICD-10 B040ZZZ. However, for clinical purposes, the default mapping might be to themore inclusive ICD-10 BH4CZZZ. Other business or analytic purposes might map differently aswell.Software Vendor Crosswalk VariationsIndependent packaged software vendors (ISVs) will have different offerings and divergentapproaches to cross-walking; some may support sophisticated rules and others won’t. Either way,if medical systems, claims systems, and financial systems house divergent rules, things will getmessy in a hurry.Consider a typical payer organization, Payer A, with two claims systems (a legacy system fromVendor A and a modern system from Vendor B), a care management system from Vendor C, aclinical editing/fraud waste & abuse system from Vendor D and an EDI gateway from Vendor E.Each vendor will provide some proprietary mechanism to cross-walk ICD-9 to ICD-10 and viceversa (for dual periods, migrations, analytics, etc.) as depicted in Figure 6.Figure 66
White PaperAny business rules for mappings would need to be entered and stored in at least five systemsas well as in any analytics systems that source data from the applications. With 19,695 GEMSmappings that have two or more potential codes, an organization would need to maintain118,170 crosswalk entries in addition to the GEMS and Reimbursement maps. The potential forerrors and rework is huge.Trending and Analytics with Historical DataMost payers and providers require at least three years of historical data for trending and analysispurposes. On September 30, 2013, all of this history will be encoded in ICD-9 nomenclature. Onthe following day and going forward, the neo history will start to be encoded in ICD-10. Any typeof trending will either require a migration of all of the history to ICD-10 or some mechanism forstepping up ICD-9 codes to ICD-10 or stepping back ICD-10 codes to ICD-9 for analysis (andmaybe both). Migrating or stepping up from ICD-9 to 10 is non-trivial and will require a standard,business rule-driven approach to avoid skewed analytics.Time and Cost will be a Formidable Adversary to Any Well-IntentionedPlan to Remediate EverythingIt’s unlikely that any organization, regardless of size, will have all of the financial, human, andtechnical resources to remediate everything that touches ICD codes in time to meet the mandates,given the expenditures and efforts required for the HIPAA 5010 and reform and/or HITECHmandates.The Solution: Master Data ManagementA master data management approach will resolve many of the aforementioned challenges, bothconceptually and practically. Master data management, as defined by the MDM Institute, is an“authoritative, reliable foundation for data used across many applications and constituencies withthe goal to provide a single view of the truth no matter where it lies.”Applied to ICD-10, a master data management approach would provide a central, managedstorage and access point for processes and systems that need to consume ICD-9 or ICD-10codes, mappings, and translations (GEMS, Reimbursement, overrides, and any other desiredmappings or hierarchies). Figure 7 illustrates how the fictional, but realistic, Payer A ecosystemcould look with an MDM solution providing a centralized storage point for disease and procedurecodes and mappings, accessible via a business process management layer. In this context, asingle set of business rules, mappings, and translations can be applied uniformly to all processesand supporting applications.ICD-10: A Master Data Problem7
Figure 7The benefits of implementing a master data management approach are widespread: Allows you to apply consistent business rules uniformly to all processes and supportingapplications without having to maintain the rules in multiple places with redundantmaintenance processes. Facilitates consistency in approach and rules when major applications are sourced frommultiple software vendors and integrated with homegrown applications. Lets firms select which systems to remediate without sacrificing compliance or analyticexcellence. Supports standard CMS mappings (GEMS and Reimbursement), but permits theorganization to override or extend the standard mappings based upon customer/tradingpartner, business process, or function. Makes it easy to update systems with future changes in mappings (ICD-11 or other future codesets) or additional value-added mappings (diseases to procedures or DRG mappings). Promotes analytic excellence by ensuring consistent results when transactions acrossmultiple systems are aggregated for analysis.8
White PaperConclusionHealthcare organizations burdened with meaningful use, healthcare reform, and HIPAA lack thetime, resources, and budget to remediate all of their systems to ICD-10 by the October 1, 2014deadline. The common approach to implementation - allowing vendors to remediate core systemswhile using crosswalks for in-house, legacy systems - is rife with challenges. These problemsinclude divergent approaches to crosswalking, difficulties in obtaining meaningful analytics withdata in ICD-9 and/or ICD-10 codes, and the inability to deal with overrides and exceptions to thestandard government mappings.A master data management approach solves these challenges by utilizing a single businessprocess management layer with centralized rules, mappings, and translations that can be applieduniformly to all applications. This facilitates a consistent approach, enables selective remediationwithout sacrificing best practices, allows for overrides, and can be easily updated with futuremapping changes.With diagnosis and procedure codes used in virtually every aspect of business operations,healthcare organizations must evaluate every approach - including the master data managementsolution - before beginning the ICD-10 transformation. The decisions made in the planning phaseswill impact clinical and business processes and systems for years to come.LEARN MORELearn more about the Informatica Platform.Visit us at www.informatica.com or call 1 650-385-5000 (1-800-653-3871 inthe U.S.).ABOUT INFORMATICAInformatica Corporation is the world’s numberone independent provider of data integrationsoftware. Organizations around the world gaina competitive advantage in today’s globalinformation economy with timely, relevantand trustworthy data for their top businessimperatives. More than 4,100 enterprisesworldwide rely on Informatica to access,integrate and trust their information assetsheld in the traditional enterprise, off premiseand in the Cloud.ABOUT HIGHPOINT SOLUTIONSHighPoint Solutions is a premier provider ofspecialized IT services with vertically-focusedbusiness consulting, system integration,professional service, and managed hostingsolutions for life sciences and healthcarecompanies. Since 2000, HighPoint Solutions’350 consultants have provided businessconsulting and technology solutions thatcontinue to deliver business value andcompetitive advantage to over 140 clientsnationwide.1150 First Avenue, Suite 450King of Prussia, PA 19406Phone: 800-238-1230Fax: 610-233-2999www.highpoint-solutions.comWritten by John Wollman, Executive Vice President, Healthcare, HighPoint SolutionsICD-10: A Master Data Problem9
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ICD-10: A Master Data Problem 3 The Inherent Complexities of ICD-10 Inhibit Proper Adoption ICD-10 vastly increases the number and complexity of disease and procedure codes over ICD-9, the previous standard enacted in 1977. ICD-10 contains 141,060 codes, a 712% increase over the 19,817 codes in ICD-9.
ICD-9 724.02 ICD-10 M48.06 Spinal stenosis, lumbar region ICD-9 720.2 ICD-10 M46.1 Sacroiliitis, not elsewhere classified ICD-9 724.8 ICD-10 R29.898 Other symptoms and signs involving the ** musculoskeletal system ICD-9 721.42 ICD-10 M47.16 Other spondylosis with myelopathy, lumbar region ICD-9 723.1 ICD-10 M54.2 Cervicalgia ICD
ICD-10 Tips from PHCS The Road to ICD-10 Flyer AMA ICD-10 Project Plan Template Educational Tools Folder Precyse University ICD-10 Physician Office Solution Brochure Precyse Catalog of ICD-10 Courses ICD-10 Precyse Apps for Physicians Resources Folder Free Resources ICD-9 to ICD-10 Crosswalk of Most Common ICD-9 .
More on ICD-10. ICD-10-PCS replaces ICD-9-CM inpatient procedure coding: ICD-9-CM procedure codes 3 to 4 numeric digits ICD-10-CM codes 7 alphanumeric digits ICD-10-PCS code format substantially different from ICD -9 Unlike ICD-9, ICD-10
Dec 14, 2010 · ICD-9. ICD-10. ICD-9. ICD-10. Inactive. Active. Combined Code Set. Core Technologies. ICD-9 and ICD-10 code values are unique. Generally, the industry is taking one of two approaches as it relates to the ICD-10 transition: Remediation: Modify/expand all systems and processes to accommodate ICD-
ICD-10 to ICD-10-CM Based on FY2017 ICD-10-CM codes Category and subcategory codes are shaded in grey and marked with an Cells shaded in pink and marked with an *indicate the preferred code when a single code maps to multiple codes (see Introduction) Reportable Neoplasms . Type of Code ICD-10 Category Chapter II (Neoplasms) ICD-10 Term . ICD .
7/13/2015 1 Tonya Mitchell, RHIT July 17, 2015 Objectives Review the History of ICD‐10 Discuss the Myths and Facts of ICD‐10 Discuss GlGeneral DttiDocumentation CtConcepts Review ICD‐10 Documentation Concepts Analyze Documentation for Top Diagnosis in ICD‐10 WHY CHANGE FROM ICD‐9 TO ICD‐10? ICD‐9 was developed in the 1970s and cannot support current
of the previous ICD-9 coding system. The volume of ICD-10 codes as compared to ICD-9 codes is significant because in ICD-10, the code size has been expanded, code values and interpretations have been redefined and specificity has been further improved. Global ICD-10 adoption The current version of ICD is ICD-10, which was adopted by the World .
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