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Cover Story: Claims and Coding


Billing Systems Financial Systems

Claim Submission Systems Compliance Checking Systems National and Local Coverage Determinations

Reporting: Provider Profi ling Quality Measurement Utilization Management Disease Management Registries/Other Registries State Reporting Systems Fraud Management Patient Assessment Data Data Sets Aggregate Data Reporting Managed Care Reporting


DRG Grouper Encoding Software Abstract Systems Compliance Software Medical Necessity

Support Systems: Case Mix Systems Utilization Management Quality Management Case Management Performance Measurement

Registration: Registration/Scheduling Systems Advance Benefi ciary Software Medical Necessity Edits

Clinical Systems: Clinical Protocols Test Ordering Systems Clinical Reminder Systems Medical Necessity Software Disease Management Systems Decision Support Systems Clinical Systems Pharmacy Systems Lab Systems Radiology Systems EKG EZG

Internal Home Grown: Systems and Customizations

*Suggested systems for evaluation. Exact list of systems varies by organization.

10 February 2011

time; ICD-9 processing and ICD-10 processing will have to coexist.

And CIOs should not forget the need for hardware upgrades (such as servers, workstations and clinical monitors). With good planning, costs can be spread over three to four years, minimizing the fi nancial impact of new capital investments.

Interfaces: The Achilles heel of ICD-10 System interfaces could be the Achilles heel in an otherwise successful ICD-10 conversion. Testing all interfaces in both directions is a critical step in the pro- cess. Interface issues are fraught with fi nger-pointing possibilities, so a test environment is crucial to dealing with interfaces before go-live. Continued support at go-live is recommended, as hidden problems will arise. It is a good practice to have a fallback plan in case of a go-live failure that requires considerable work to fi x.

Understanding crosswalks and GEMS The third issue is the creation of institution-specifi c crosswalks between ICD-9 codes and ICD-10 codes in both directions. Crosswalks are a one-to-one mapping that is application and institution specifi c. There is a free available mapping scheme called general equiva- lence mappings (GEMS) that organizations can use as a starting point where appropriate.

GEMS are a mapping to “probable” matching codes. These GEMS were created by the CDC and CMS as a general-purpose translation tool to ensure national data consistency post-transition. Since there are many more ICD-10 codes, there will be numerous instances of one-to-many mapping. For example, angioplasty has one ICD-9 code, but 85 ICD-10 codes. GEMS are available for a limited time (three years) and should be viewed as a short-term starting point for system crosswalks. GEMS are “diamonds” in the rough that need to be cut and polished to meet the needs of each individual organization. Finally, IT and HIM should be the leaders of the crosswalk-building team. In fact, these two depart- ments must work closely together on the ICD-10 transition for the next three to four years, as men- tioned above.

Checking your list … twice

The three issues explored in this article – systems as- sessment, interfaces and crosswalks – are high-visibility components of the transition; however, they are not meant to represent all the issues to be reckoned with. Education, communication and collaboration are the keys to a successful ICD-10 transition. While it’s not yet the time to panic, it is certainly time to aggressively move forward. Let the games begin!


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