ICD-10 Software Selection for Health Care Coding

The software selection process has two main components:

1. Create a list of candidate vendors (the long list) then send a request for further information.

2. Select the best suited (short list) and then get detail on any gaps in the software vendor solution compared to the identified requirements in a request for proposal (RFP).

* Define needs and selection criteria

* Create long list

* Create the request for proposal

* Evaluate responses

* Create short list

Usually subject matter expertise in the solution area is helpful.  We work with clients in financial services, eCommere, Learning Management Systems, CRM, Talent Management, and especially health care these days to find the right solution.

One of the recent developments in my opinion is that opportunists have arrived in the health information management business, offering quick fixes to problems that just aren’t.  One case in point is ICD-10, a new standard that requires every HIPAA Covered Entity including all health insurance firms (health plan or payor), as well as health care providers (hospital, lab, billing company and physician) to change the way they enter both diagnosis AND procedure codes.

The change from ICD-9 to ICD-10 represents more than just a change in coding, it involves a new reimbursement paradigm.  Some software vendors offer simple cross references or “cross walks” and others use a similar approach called a GEM or “general equivalence map.”  It turns out that neither of these are going to be a good fit because ICD-10 involves going from less detail to more.  Going the other way isn’t really practical. Crosswalks combined with good old rolling up the sleeves and expertise will work, and a tool might help if it isn’t viewed as a panacea.

For example, Diabetes Mellitus in ICD-9 might be,

“250.X, where:

4th digit identities type of complication
5th digit “1” identified juvenile-onset
5th digit “0” identified adult-onset

And if we want to be more specific in ICD-10 it might look like this:

E10.X Insulin-dependent
E11.X Non-insulin dependent
E12 Malnutrition-related
E13 Other specified
E14 Unspecified4th digit for type of complication

Or it might be:

E08 Diabetes due to underlying condition
E09 Drug or chemical induced diabetes
E10 Type 1 diabetes E11 Type 2 diabetes E13 Other specified diabetes mellitus
E14 Unspecified4th digit identifies type of complication5/6th digit for type of complication

Here’s the issue:

Diabetes mellitus codes expanded to include the classification of the diabetes and the manifestation.

The category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes

There are things that are no longer classified as controlled / uncontrolled:

E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease
E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.11, Type 1 diabetes mellitus with ketoacidosis with coma
E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy

Now, how are we going to mitigate all of this this with a tool? Some vendors claim that insurance companies can take in an ICD-10 code, not make changes to their back office claims systems for new procedure codes, and pay on the old codes.While short term this might be a viable approach for some, I don’t think this approach is a long term strategy and it has risks.

There are some good solutions to the problem. However, there are no quick fixes with a tool. If you are shopping for a tool for converting diagnosis and procedure codes, make sure that you include subject matter experts in the area on your selection team, and create challenges for the vendors to overcome that represent real-world clinical scenarios – not canned demonstrations. That applies in any industry but especially in so called code converters or neutralizers.

Master Data Management on the other hand can be used along with careful thinking about the specific health plan or provider medical policies. In our experience, not only are tools not appropriate by themselves, but there are regional and functional differences in the coding. And, physicians just won’t change their behavior unless education from trusted colleagues in their area help provide the needed information so that they can see why they need to change.

In addition, what physicians and coders do now and what they do under ICD-10 is of critical importance. Education cannot be overlooked. The industry is moving gradually from a reimbursement and procedure focused one to quality. There are some important quality measures with big carrot and stick that many expect will influence the behavior of health care providers and ultimately the entire health care industry.

Therefore, tools, data, people and process have to be applied in a harmonious way without viewing any of them alone as magic bullets, while being sensitive to regional practices as well as the role of each player in the health care service chain.

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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