Migrating from ICD 9 to ICD 10? Build your own Custom Code Map

While most providers would have migrated to ICD-10 post October 2014, some of the payers that you interact with might not be ICD-10 compliant. This means, while sending claims to some of these non-compliant payers, providers would need a code mapping crosswalk, translating claims from ICD-10 to ICD-9 to ensure that they are able to generate and process ICD-9 claims. Apart from this, even prior to the October deadline, providers need to undertake a financial neutrality analysis to plan for the possible impact on reimbursement variances between pre and post change landscape as well as remediate any reporting variances as a result of code changes.

The healthcare industry usually follows General Equivalence Mappings (GEMS) reimbursement maps, as a primary crosswalk map for undertaking financial neutrality analysis. GEMS reimbursement maps, provide a one-to-one code map, and include clinically non-equivalent mappings in its fold. Appx 30% of all one-to-one maps are not clinically appropriate, thereby questioning the neutrality analysis performed using these maps. Also, to guard against reimbursement variations post compliance, you need to undertake financial neutrality testing to assess these 1 to 1 maps for data-sets pertaining to the patient population they cater to.

The second most important but hidden impact is on the reports using ICD-9 codes generated by providers. All of these codes need to map to corresponding ICD-10 code maps (one-to-many) for diagnosis reports following the migration. Unfortunately, here too the GEMS maps come up short. Appx 30-40% of the GEMS indicated code maps need to be enhanced to map additional ICD-10 codes, so as to cover all possible clinical conditions. Else, providers risk generating inaccurate reports which may affect critical inputs for budget and financial planning, regulatory compliance, and operations management.

For example, if a hospital wants to analyze data pertaining to patients with mitral valve disease, they would probably be using the ICD9 code 394.9 (Other and unspecified mitral valve diseases). This code maps to only one ICD-10 code I05.8 (Other rheumatic mitral valve diseases) as per the GEMS map. However, another ICD-10 code I05.9 (Rheumatic mitral valve disease, unspecified) is also clinically equivalent to the ICD-9 code 394.9.

Some examples (Year on Year/ Quarter on Quarter) where Custom Reporting Maps can be used:


Indicative Quality Measure

Diagnosis Used

Quality Measure Acute Myocardial infarction core measure set AMI (ICD-10) - I23.8
Stroke (STK) core measure set Cerebellar stroke syndrome (ICD-10) G46.4
Brain stem stroke syndrome (ICD-10) G 46.3
Physician Groups & Medical Home Avoidance of anti-biotic treatment in adults with acute bronchitis (AAB) Acute bronchitis(ICD 10) - J20.0
Diabetes Mellitus: Hemoglobin A1c poor control Type 1 diabetes mellitus (ICD-10) E10
Type 2 diabetes mellitus (ICD-10) E11
Drug or chemical induced diabetes mellitus (ICD-10)  E09
Strategic Reports OR room utilization by case type Diagnosis based data segregated by procedure type and specialty
Operational, financial analysis report Capacity and utilization Average length of stay, acute care, case mix adjusted
Trend and Predictive analytics reporting Readmission rate Using ICD codes for calculating the possible readmission of patients based on certain diagnosis
HEDIS reporting Comprehensive diabetes care Type 1 diabetes mellitus (ICD-10) E10
Type 2 diabetes mellitus (ICD-10) E11

How it Works?

Custom Code Mapping for Reimbursement Reporting