A P P L I C A T I O N S A WHITE PAPER SERIES THE ICD-9 TO ICD-10 MIGRATION POSES A MAJOR CHALLENGE FOR HEALTHCARE PAYERS AND PROVIDERS. HOWEVER, AN ICD-10 IMPLEMENTATION IS A REMARKABLE OPPORTUNITY TO UPGRADE THE QUALITY OF HEALTHCARE DATA. Syntel's Perspective on ICD-10 Migration Will Crosswalk Deliver the Value it Promises?
TABLE OF CONTENTS 1 2 3 4 5 6 ABSTRACT THE SITUATION EVALUATING CROSSWALK STRATEGY POTENTIAL APPLICATIONS OF CROSSWALK IN ICD-10 MIGRATION HOW BUSINESS RULE TRANSLATIONS IN ICD-10 ARE CRITICAL TO TRANSITION TREND ANALYSIS HOW THEY CAN PREDICT UPCOMING CHANGES CROSSWALK AS BASIS FOR ICD-9/10 TEST DATA PREPARATION DATA/DESIGN ANALYSIS : BEST PRACTICES FOR CONVERSION CONCLUSION ABOUT SYNTEL nsure10 SM TRANSLATOR Abstract The imminent ICD-9 to ICD-10 (International Classification of Diseases version 10) migration poses a major challenge for healthcare payers and providers, as they rush to meet the compliance deadline of October 1, 2014. The implementation of ICD-10 is a remarkable opportunity to upgrade the quality of healthcare data and will involve compliance from every aspect of the healthcare business. A predominant issue in the ongoing ICD-10 implementation has been the use of a so-called crosswalk between the old and new code sets to help the industry make the transition. While a healthy debate continues about using a crosswalk as a migration strategy, a well-planned business needs analysis will be crucial in determining its suitability for your organization. This paper will outline Syntel s views on crosswalk strategies and several important aspects related to crosswalk implementations. We will also set out a comprehensive assessment approach that will enable organizations to determine whether a crosswalk can deliver the value it promises. 2012 SYNTEL, INC.
The Situation The impending implementation of the ICD-10 code set is a remarkable opportunity for healthcare payers and providers to upgrade the quality of data from old to new code sets. Since its beginning, the ICD has undergone a number of iterations. The U.S. Department of Health and Human Services (HHS) mandated the move from ICD-9 to an enhanced ICD-10 version to be implemented by October 1, 2013. This is a far more complex scheme reflecting changes in disease detection and treatment procedures. Crosswalk is a general term used to refer to the bi-directional relationship that exists between the ICD-9 and ICD-10 codes. To take into consideration the clinical equivalence that exists between the two code-sets, General Equivalence Mappings (GEMs) are applied in a crosswalk. GEMs which were developed by CMS in association with 3M exhibit the multiple mapping scenarios that exist between ICD-9 and ICD-10. These mappings offer both forward (ICD-9 to ICD-10) and backward (ICD-10 to ICD-9) mappings. There has been much debate around the use and efficacy of a crosswalk in migration. It should be noted that a crosswalk may not be a comprehensive solution for this migration, but it can definitely assist in certain areas that can help meet the migration deadline in an effective and streamlined way. Evaluating Crosswalk Strategy Before embarking on the ICD transformation journey, it is imperative for an organization to establish whether or not a crosswalk is suited to meet its conversion needs. There are a number of issues involved that can help determine its selection and deployment. Let s take a look at some typical questions that need to be answered: Is the application nearing the end of its lifespan? If the application to be mapped is slated for retirement soon (within two years from the date of ICD-10 code implementation), a crosswalk can be usefully incorporated within the existing system. This may help reduce remediation expenses as well as lower the cost of your investment in ICD-10. How critical is the application? Application criticality is another important factor that will determine whether or not a crosswalk strategy is advisable. Crosswalk is definitely not a solution for remediating the claims processing engine. However, crosswalk can typically be useful for applications which use a group of codes for claim processing (mapping ICD-9 data groups to ICD-10, then back again to the same ICD-9 codes for reimbursement). Therefore, the significance of the application would determine whether or not a crosswalk strategy will be successful. Additionally, it could be a practical solution for smaller reporting applications. e.g.: ICD-9 Code 740-742 (Congenital Anomalies) maps to ICD-10 Q00- Q07 (Congenital Malformations, Deformations and Chromosomal Abnormalities) and the remapping to ICD-9 will be used for reimbursement. Does the application use only Medicare Severity-Diagnosis Related Groups (MS-DRG) for reimbursement? The MS-DRG system divides traditional DRGs into categories of similar MS-DRGs based on the presence or absence of a complicating condition (CC). The idea is to pay hospitals more fairly based on the level of care required to treat patients. Admissions for patients with a CC should receive a higher Medicare payment than otherwise, which helps lower hospital costs and increases the appropriate payments where necessary. A study by CMS has shown that if reimbursements are made by MS-DRG, the payment variations are less than 0.5 percent 1. However, this will hold true if CMS does not come up with new DRGs, as the CMS study is based on MedPAR claims data. Individual payers will use their own translational rules for mapping, so payment variations could be different. Mapping distribution statistics There are multiple code mapping scenarios in the applications, namely one-to-one, one-to-many, many-to-many and one-to-cluster. If a majority of the codes in use belong to the one-to-one category, a crosswalk can be a possible solution with a workflow change. However, it should be understood that a workflow change is not needed for all one-to-many code cases. Dependency on other applications or many interfaces with other applications will also be a factor. 1. http://www.cms.gov/icd10/downloads/091510_agenda_handouts.pdf
For the codes that do not have a one-to-one mapping, the following scenarios will be applicable. Mapping Categories ICD-10 to ICD-9 ICD-9 to ICD-10 No Match 1.2% 3.0% 1-to1 Exact Match 5.0% 24.2% 1-to-1 Approximate Match with one Choice 82.6% 49.1% 1-to-1 Approximate Match with Multiple Choices 4.3% 18.7% 1-to-Many Match with one Scenario 6.6% 2.1% 1-to-Many Match with Multiple Scenarios 0.2% 2.9% STATISTICS FOR MAPPING DISTRIBUTION BASED ON GEMS 4.3% 6.6% ICD-10 to ICD-9 0.2% 1.2% 4.3% ICD-9 to ICD-10 2.9% 2.1% 3.0% 18.7% 24.2% 82.6% 49.1% No Match 1-to-1 Exact Match 1-to-1 Approximate Match with 1 choice 1-to-1 Approximate Match with Multiple Choices 1-to-Many Match with 1 Scenario 1-to-Many Match with Multiple Scenarios No Match 1-to-1 Exact Match 1-to-1 Approximate Match with 1 choice 1-to-1 Approximate Match with Multiple Choices 1-to-Many Match with 1 Scenario 1-to-Many Match with Multiple Scenarios Potential Applications of Crosswalk in Migration At Syntel, our experience working with leading healthcare payers and providers on their ICD-9 to ICD-10 migrations has shown that a crosswalk can be extremely useful in meeting the complex issues involved in the transition. However, we believe that there are certain areas where crosswalk can be used in the remediation exercise that need significant attention. These areas include: How business rule translations in ICD-10 are critical to transition Trend analysis how they can predict upcoming changes Crosswalk as the basis for ICD-9/10 test data preparation Data/design analysis: best practices for conversion I. How Business Rule Translations in ICD-10 are Critical to Transition Crosswalk implementations rely heavily on business rules and the codes used within them. Our experience in ICD-10 remediation suggests that business rules are coded in terms of ICD-9 data and a crosswalk tool that contains ICD-9 to ICD-10 mapping will help in translation of these rules. Typically, the translations can be divided into the following kinds:
Dependency of Rules on a Single Code (hard coded values) Codes with one-to-one mapping will use the equivalent ICD-10 code. The ability to do so with ease is critical to make crosswalks more agile. However, in case of one-to-many mappings, a decision needs to be made on the basis of the purpose of the mapping. For instance, if a code belongs to an inclusion or exclusion list (of diagnosis/procedure codes), you also need to include or exclude all the equivalent mappings on that list. Dependency of Rules on a Range of Codes/Multiple Codes For business rules dependent on a range of values or codes, it is important to ensure that the relevant mappings will be part of the new ICD-10 rule. Hence, the need to introduce new codes as part of ICD-10 codes must be determined. Clinical coders will help establish whether the newly created ICD-10 list of codes fully represents the existing condition in ICD-9, and if they need to be replicated uniformly across the organization. For example, assume code 198.1 (SEC MALIG NEO URIN NEC) is found on an exclusion list. Since there is no exact mapping available for this code, it is mapped to two ICD-10 codes specifically C79.11 (secondary malignant neoplasm of bladder) and C79.19 (secondary malignant neoplasm of other urinary organs). Therefore, both codes would need to be included in the exclusion list. While making the transition it may be simpler to adopt a section-wise or chapter-wise approach in mapping codes for translating business rules between ICD-9 and ICD-10. For instance: Chapter 3 ( Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders ) of ICD-9 is mapped to Code range E00-E89-Endocrine, Nutritional and Metabolic Diseases. II. Trend Analysis How They Can Predict Upcoming Changes Timely identification of newly emerging trends is very important to all organizations. It is undoubtedly a critical area which can redefine an organization s success and also reap the benefits of ICD-10 codes. Most trend analysis refers to prior-year data to accomplish basic scenarios. For example, business areas like Actuarial and Care Management typically involve applications that use ICD codes for analysis and prediction of emerging trends. Depending on the organization, situations might arise where the trend analytics application may refer to the previous 12 months of data in December, 2013. In such cases, the organization would have only three months of ICD-9 data available for reporting purposes. In this scenario, the workaround is to convert the incoming ICD-10 data back into ICD-9 2 and run the application running as it did previously. However, before resorting to this conversion, it is imperative to determine whether ICD-9 codes are actually used as KPIs (Key Performance Indicators) for any of the reports generated. Customized Mappings Customized mappings are specific mappings that are derived from General Equivalence Mappings by resolving the ambiguities between ICD-9 to ICD-10 coding. The logic for resolving one-to-many cases to one-to-one depends on either Clinical Equivalence or Financial Neutrality. Once all mappings have been converted to one-to-one codes, customized mappings can be used for transactional purposes. Typically, customized mappings can be of use in applications for trend analysis to aid conversion of ICD-10 codes to ICD-9 codes. Some organizations seek to have consistent mappings across business processes and areas, while others aim to create different sets of mappings to be used by business areas or trading partners. However, a proprietary methodology will aid in choosing the best-suited mappings, depending on their intent of use. III. Crosswalk as the Basis for ICD-9/10 Test Data Preparation A crosswalk can be used to generate test data, which forms the basis of any simulation exercise or to test any system remediated to accept ICD-10 codes. IV. Data/Design Analysis: Best Practices for Conversion Any outcome analysis or system design validation requires the creation of ICD-10 data. This ICD-10 data can be created from existing ICD-9 data using customized rules. For example, the patient s gender can help resolve one-to-many code cases. This ICD-10 data can then be employed in new designs for: Verifying payment variance in the reimbursement area Payment variance can be determined by analyzing the reimbursement history and measuring the difference in reimbursements made using ICD-9 and ICD-10 codes. This can assist in validating whether the ICD-10 system is producing accurate results. 2. Backward mapping will not work in areas where trend analysis is used to set some triggers.transforming all triggers to ICD-10 requires input in ICD-10 codes.
Determining non-payment outcomes Here the simulated ICD-10 data can be used to determine whether the design and changes in a system will produce equivalent results in the ICD-10 environment or pass off. For example, we can use the simulated data to determine whether the same number of patients are eligible for a care program in both the ICD-9 and ICD-10 scenarios. Insights Different Processing Logic Based on Certain ICD Codes In specific scenarios, claims related to mental health diagnosis could be routed to a third party for re-pricing. Claims with a primary diagnosis code belonging to mental health diseases could be identified for this condition. A section-wise mapping (group of codes) would be useful here rather than using individual translations through a crosswalk. e.g.: Chapter 5, Mental disorders 3 contains ICD-9 codes in the range of 290-319 which are mapped to F01- F99 of ICD-10. 3 Exclusion List for Bypassing Pre-Authorizations In certain cases, the exclusion list bypasses the pre-authorization process. For example, at one large healthcare payer, the criteria for selecting claims for pre-authorization edits was dependent on a list of ICD codes, including both diagnosis and procedure codes. A crosswalk between ICD-9 and ICD-10 proved helpful to retrieve the list to be used in an ICD-10 mapping, making it a practical and convenient proposition. A pre-authorization list usually contains only procedure codes, but there could be situations where both diagnosis and procedure code will be part of pre-authorization edit exclusion code list. Conclusion ICD-10 compliance has an immense potential to transform healthcare organizations business processes. However, the decision to achieve compliance through a full remediation or a crosswalk solution is ultimately up to each organization. While a crosswalk solution will provide significant benefits in the short run, its long-term benefits will depend on the organization and how it is implemented. The factors outlined in this paper, if taken into account, can make a significant difference in the overall implementation program and the associated costs. In the healthcare scenario, if a well-planned strategy is conceived and the key factors are taken into account, a crosswalk implementation can justify the costs and challenges associated with the transition. The decision will also impact whether an ICD-10 transition serves only to meet the compliance deadline, or if it addresses other issues as well. Syntel s Approach Implementing a quick and cost effective translation logic as part of a crosswalk strategy requires careful planning to minimize the financial and productivity impacts. Although the overall changes are minimal, there are significant risks related to code conversion. Therefore, it is of paramount importance to have a holistic approach in place that allows custom map development based on your organization s needs through an efficient tool like Syntel s nsure10 SM Translator. The Translator tool provides a workflow feature that enables critical decision making and traces mapping revisions that can be used to build customized mappings by business area. Syntel s deep experience implementing ICD-10 initiatives for healthcare organizations of all types and sizes gives us the perspective required to guide your organization through this process and recommend a choice between a centralized or decentralized implementation. In addition, our SOA-based Translator enables seamless interfaces with internal applications. The final piece of the puzzle is Syntel s ability to provide thorough testing in order to mitigate risk. To learn more, please visit Syntel online at www.syntelinc.com/icd10 3. The complete chapter-wise listing of ICD-9 to ICD-10 mapping can be found at: ICD-9 to ICD-10 Chapter wise Reference sheet
About Syntel s nsure10 Translator Syntel s nsure10 Translator offers the expert solution you need to achieve rapid and accurate translation between ICD code systems and provide realistic and business-oriented services that align to your remediation strategy. Combined with our expert services, it will reduce time and resources required for ICD-10 transition while improving accuracy and consistency. Syntel s nsure10 SM Translator is an efficient and valuable resource that helps reduce the effort and cost required to find the exact or best-suited code match. Built specifically for payers, providers, clearinghouses, TPAs and other medical coding professionals, our nsure10 Translator offers flexibility and can be customized easily. It is simple and easy to adapt to your requirements by bridging the gaps that exist between the standard practices followed by your organization and the new mandates. A platform independent solution, Syntel s nsure10 Translator acts as a bridge between multiple systems and supports coordinated changes. Additionally, the nsure10 Translator can be used for hypothesis testing so you can arrive at the ICD- 10 code sets for an application behavior, training even real-time conversion in the data trend analysis process. nsure10 Translator Architecture Applications Legacy System Open System Predefined Mainframe Interface Service Interface Business Layer Enterprise Database customized to use DB2 Users Medical coders Claims specialists Administrators Presentation Layer Accept inputs Returns the appropriate codes Data uploads Uploads processor Forward/backward mapping processor Customization/ history processor Analytics processor Data Access Layer Mapping DB GEM Mappings Reimbursement mapping Mappings history Reimbursement processor Customized mappings SECURITY EXCEPTION HANDLING nsure10 Translator Tool Boundary The Translator Advantage Coherent solution to facilitate rapid navigation from ICD-9 to ICD-10 codes Flexible and platform independent Provides intelligence by conducting data analysis on pre-built General Equivalence Mappings (GEM) to suggest the best match Allows real-time or batch code translation Ability to work on different versions of GEM files Can be used to conduct simulation studies for financial neutrality Extensive cost and effort reduction through structured code customization Enables you to trace mapping revisions and build customized mappings by business area Flexibility for downstream applications to continue functioning with ICD-9 codes until migration Delivers consistent mapping interpretation between two versions of code sets, with centralized mapping and lookup availability
about SYNTEL: Syntel provides custom outsourcing solutions to Global 2000 corporations. Founded in 1980, Syntel's portfolio of services includes BPO, complex application development, management, product engineering, and enterprise application integration services, as well as e-business development and integration, wireless solutions, data warehousing, CRM, and ERP. We maximize outsourcing investments through an onsite/off-shore Global Delivery Service, increasing the efficiency of how complex projects are delivered. Syntel's global approach also makes a significant and positive impact on speed-to-market, budgets, and quality. We deploy a custom delivery model that is a seamless extension of your organization to fit your business goals and a proprietary knowledge transfer methodology to guarantee knowledge continuity. SYNTEL 525 E. Big Beaver, Third Floor Troy, MI 48083 phone 248.619.3503 info@syntelinc.com visit Syntel's web site at www.syntelinc.com