Saturday, July 28, 2012

ICD-10 Tools: Beyond Simple Mapping and Translation

A number of companies are touting ICD-10 tools to help payers and providers with their ICD-10 assessment and remediation efforts. The range of functionality and features offered by these tools is growing by the day. Some are very purpose-specific and others appear to be taking the Swiss Army knife approach by offering dozens of capabilities; few of which appear to provide any real depth and value.

Whether planning to use a 3rd party tool or creating one of your own, there are a few functions and features to consider beyond the common mapping and translation functionalities offered by most 3rd parties:

1. Analyzing Your Data, Software and System Configuration Tables

As part of your ICD-10 assessment, you’ll have to answer a number of questions:

a. How should we plan for changes to contracts and medical policy?

b. How can we identify areas where additional training and / or provider outreach is necessary?

c. How can we predict the financial implications of the ICD-10 implementation?

d. How do we create an ICD-9 to ICD-10 and an ICD-10 to ICD-9 translation that can be utilized by all departments or specialized versions for specific departments?

Scanning, analytics and reporting capabilities are critical to help answer these questions. A good ICD code scanning and analyzer tool will identify how ICD-9 codes will translate to ICD-10 codes by code occurrence, dollar amount, unspecified codes, etc.

For instance, an unspecified codes report contains a count of the occurrences of all ICD-9 codes defined as unspecified can be used to identify the codes where you might wish to create an outreach and education plan to those providers submitting them; in order to encourage use of the enhanced granularity found in the ICD-10 code set.

2. Handling Groups, Lists and Ranges of Codes

Many business processes and software applications use groups of ICD codes for medical review determination, fraud and abuse detection, reporting quality measures, coding benefits, coverage determination, medical policy editing, and provider contract assignment. These groups, lists and ranges of codes must be updated to include their ICD-10 code equivalents.

Your tool or process should be able to identify and maintain ICD-9 and ICD-10 group and range equivalencies; with the ability to define master and purpose-specific variations.

3. Normalizing Diagnoses Codes for Testing and Production Purposes

Part of your remediation effort will involve conversion of historical data containing ICD-9 codes. You’ll also need to create ICD-10 test data from ICD-9 coded records. Depending on how your systems are remediated, you may need to convert back and forth between ICD-9 and ICD-10 codes as part of your normal business processes – especially during the period before and after the cutover.

For instance, when processing a claim requiring a prior authorization and the incoming claim has an ICD-10 code but the prior authorization was approved with an ICD-9 code, a crosswalk of the ICD-10 code that comes in on a claim to its equivalent ICD-9 code is required. A similar need presents itself when conducting medical reviews across the transition period, when creating reports for quality measures, HEDIS, fraud and abuse, etc - you’ll need to be able to review and analyze a normalized set of diagnoses data.

4. Incorporate Reference Information and Allow for Annotations

When reviewing the I-9 to I-10 and I-10 to I-9 diagnosis and procedure code mappings to determine the their accuracy, as well as any possible additions you may want to make to add specificity to the mappings, it will be necessary to easily access ICD-10’s tabular Indexes, CMS guidelines, and CMS’s General Equivalence Mappings (GEMs). Having this information accessible from within the tool and having the ability to annotate and adjust mappings and descriptions will reduce time associated with accessing these information sources from various locations while providing historical reference and audit value.

So whether licensing a tool from a 3rd party or building your own – with or without the assistance of a consultant – consider functionality and features beyond simple mapping and translation.

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