Medisoft ICD 10 Implementation and Deadlines

The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.

ICD-10 provides more specific data than ICD-9 and better reflects current medical practice. The added detail embedded within ICD-10 codes informs health care providers and health plans of patient incidence and history, which improves the effectiveness of case-management and care-coordination functions. Accurate coding also reduces the volume of claims rejected due to ambiguity. Here the new code sets will:

• Improve operational processes across the health care industry by classifying detail within codes to accurately process payments and reimbursements.
• Update the terminology and disease classifications to be consistent with current clinical practice and medical and technological advances.
• Increase flexibility for future updates as necessary.
• Enhance coding accuracy and specificity to classify anatomic site, etiology, and severity.
• Support refined reimbursement models to provide equitable payment for more complex conditions.
• Streamline payment operations by allowing for greater automation and fewer payer-physician inquiries, decreasing delays and inappropriate denials.
• Provide more detailed data to better analyze disease patterns and track and respond to public health outbreaks.
• Provide opportunities to develop and implement new pricing and reimbursement structures including fee schedules and hospital and ancillary pricing scenarios based on greater diagnostic specificity.
• Provide payers, program integrity contractors, and oversight agencies with opportunities for more effective detection

General Equivalency Mappings (GEMs)

General Equivalence Mappings (GEMs) attempt to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification. The tool allows coders to look up an ICD-9 code and be provided with the most appropriate ICD-10 matches and vice versa. Although, GEMs are not a "crosswalk" and are merely meant to be a guide. Users should exercise clinical judgment when choosing the appropriate code or codes to map between ICD-9 and ICD-10 in either direction. The GEMs are a very useful tool, but it is not a substitute for a complete system change over to ICD-10.

For most physician practices, GEMs will be of limited use and may not be appropriate since coding should occur directly to ICD-10 based on actual clinical documentation, rather than a mapping from existing ICD-9 codes. In some instances, GEMs can be helpful in validating your coding practices to help identify some codes in ICD-10 relative to existing ICD-9 for the purpose of training and validation. The ICD-10 codes will be increasing from approximately 15,000 ICD-9 codes to 150,000 ICD-10 codes, although coders will not need to know every code. GEMs can be compared to a phone book— coders will not use every number, but it is nice to know they are all there. Visit the CMS website at http://www.cms.gov/ICD10 for more information on GEMs.

There is a lot of formatting and structure that is different in ICD-10-CM than it is in ICD-9. Because of the higher level of specificity, for those coders that don’t have a strong understanding of anatomy and pathophysiology, they might need a refresher on some courses that will help bring them up to speed with a higher level of specificity that’s found in the new code set. And keep in mind that they are also going to have to code into dual systems, for some period.