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Transition to ICD-10-CM could cause financial disruption, errors among pediatric practices
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The United States health care system will transition to the International Classification of Diseases, 10th Revision, Clinical Modification in October 2015. Thirty-nine percent of convoluted pediatric diagnosis codes could potentially cause financial disruption and various administrative errors during the transition, according to study findings in Pediatrics.
Rachel Caskey, MD, MAPP, of the University of Illinois at Chicago, and colleagues analyzed Illinois Medicaid ICD-9-CM data to assess differences between ICD-9-CM and ICD-10-CM mappings. They identified 636 ICD-9-CM diagnosis codes as convoluted or high-cost, and classified them into information loss, overlapping, inconsistent, or consistent categories. Researchers calculated reimbursement by Medicaid for each category.
Rachel Caskey
Information loss was used when the transition obscured a clinically significant diagnostic distinction, which could result in the loss of relevant clinical details. The overlapping category included ICD-9-CM codes that needed additional clinical information to understand their mapping in ICD-10-CM. An inconsistent classification indicated ICD-10-CM codes were clinically different from the ICD-9-CM codes to which they were mapped. A consistent classification indicated ICD-9-CM and ICD-10-CM codes were consistent and clinically intuitive.
Twenty-six percent of all pediatric ICD-9-CM codes were considered convoluted, which indicated that 74% of codes were readily transitioned. Twenty-seven ICD-9-CM codes had no ICD-10-CM mapping due to redacted or non-translated diagnosis codes. Researchers found code classification discrepancies among 132 codes; most of these (111 of 132) were minor differences in clinical interpretation of the mapping.
Forty-percent of the 636 convoluted codes were categorized as information loss (14%); overlapping categories (18%); or inconsistent (7%). ICD-9-CM codes for pregnancy and postpartum complications that required additional clinical information in the transition were categorized as overlapping.
Regarding Medicaid reimbursement, codes in the information loss category totaled $455,320; codes in the overlapping category totaled $399,302; and codes in the inconsistent category totaled $156,637 in reimbursement.
“The potential for financial disruption and administrative errors from 39% of pediatric diagnosis codes (8% of Medicaid reimbursement) necessitates special attention to these codes in preparing for the transition to ICD-10-CM for pediatric practices. Many pediatric practices function on a thin financial margin in which 3% to 5% of codes resulting in billing errors could have a significant financial impact. Sufficient planning to mitigate this challenge and prepare is necessary,” the researchers wrote.
Alexander G. Fiks, MD, MSCE, and Robert W. Grundmeier, MD, both from the Children’s Hospital of Philadelphia, added in an accompanying editorial that appropriate ICD-10-CM training should be provided to billers, staff, clinicians, and others using the data: “In addition, we recommend that all health systems generate reports of their most frequent diagnoses to determine which may be subject to errors, based on this analysis by Caskey and their own review.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Richard Lander, MD
Having reviewed the article on ICD-10-CM transitioning from Pediatrics, I think Dr. Caskey accurately summarized the authors’ findings. There certainly is a significant risk that pediatricians will suffer financially from the 636 diagnosis codes discussed that were “convoluted” or “high-cost.” The monetary figures listed were for Medicaid payments, and if that information is extrapolated to commercial insurance plans, the potential loss would be even greater.
An issue of importance, which I think is overlooked, is where the authors write “… the insurance companies… (through mapping used) a different ICD-10-CM code which could result in financial disruption due to billing errors.” I wonder if they were referring to a holdup of claim payments due to the changed diagnosis coding or would the insurance companies use that different diagnosis code to down-code the chosen CPT code utilized, therefore paying for a lower degree of service?
As a side note, we should not use the term “reimbursement” when referring to payment from insurance companies. The insurance companies are not paying us back — they are paying for our services, which is an important difference.
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