In the GEMS maps from ICD-10 to ICD-9: • There are 7,239 instances in the mappings for diseases where a single ICD-10 code can map to more than one ICD-9 code.
• There are 7,241 instances in the mappings for procedures where a single ICD-10 code can map to more than one ICD-9 code.
In the reimbursement maps from ICD-10 to ICD-9: • There are 3,684 instances in the mappings for diseases where a single ICD-10 code can map to more than one ICD-9 code.
• There are 2,135 instances in the mappings for procedures where a single ICD-10 code can map to more than one ICD-9 code.
It’s clear that the depth and breadth of ICD-10 and the increased specifi city of diseases and procedures create many opportunities for payers and providers to promote better health while constraining costs. Yet the many-to-many nature of the relationships makes it challenging for healthcare payers and providers to: • Process transactions; • Analyze their businesses; and • Maintain compliance with regulatory requirements.
Different rules for different purposes
While CMS has tried to create clarity with GEMS and re- imbursement mappings, the results aren’t encouraging – GEMS ICD-10 to ICD-9 mappings have 5.1 percent exact matches for diseases and only .10 percent exact matches for procedures; GEMS ICD-9 to ICD-10 mappings have 20.1 percent exact matches for diseases and 1.2 percent exact matches for proce- dures. With so few exact matches, organizations will need to defi ne their own business rules for specifi c trading partners and business functions that override the government mappings. For example, consider the ICD-10 code S2241XB: Multiple fractures of ribs, right side, initial encounter for open fracture.
Figure 3 According to GEMS (represented by light blue lines in
Figure 5), 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 Neck For fi nancial purposes, assuming that there is signifi cant dif- ferentiation in cost and reimbursement between an ultrasound of the brain and an ultrasound of the neck, the default mapping would likely be to ICD-10 B040ZZZ. However, for clinical purposes, the default mapping might be to the more inclusive ICD-10 BH4CZZZ. Other business or analytic purposes might map differently as well.
Software vendor crosswalk variations According to GEMS mappings (represented by blue lines
in Figure 3) and reimbursement mappings (represented by the green lines), this ICD-10 code can map to: • 807.12: Open Fracture of Two Ribs • 807.13: Open Fracture of Three Ribs • 807.14: Open Fracture of Four Ribs • 807.15: Open Fracture of Five Ribs • 807.16: Open Fracture of Six Ribs • 807.17: Open Fracture of Seven Ribs • 807.18: Open Fracture of Eight or More Ribs
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Independent packaged software vendors (ISVs) will have different offerings and divergent approaches to crosswalking; some may support sophisticated rules and others won’t. Either way, if medical systems, claims systems and fi nancial systems house divergent rules, things will get messy in a hurry. Consider a typical payer organization, payer A, with two claims systems (a legacy system from vendor A and a modern system from vendor B), a care management system from vendor C, a clinical editing/fraud waste and abuse system from vendor D, and an EDI gateway from vendor E. Each vendor will need to provide some way to crosswalk ICD-9 to ICD-10 and vice versa (for dual periods, migrations, analytics, etc.) as depicted in Figure 6.
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• 807.19: Open Fracture Of Multiple Ribs Unspecifi ed The reimbursement map entry for this ICD-10 code is to 807.12, Open Fracture of Two Ribs. Consider a situation where a few trading partners are dominant in a given market and may be strong enough to dictate policy. For example, hospital A might dictate to payer A that the proper mapping for them is to 807.19 (unspecifi ed ribs fractured) and hospital B might dictate to payer A that the proper mapping for them is 807.12. In this situation, an organization needs to be able to override the government mappings, as represented by the red lines in Figure 4.
Additionally, the mappings might be overridden differently by business process or function. For example, consider the ICD-9 code 88.71: Diagnostic ultrasound of head and neck.