This is the first of a three-part blog series which will explore why many billing systems are not equipped to meet the more stringent ICD-10 coding requirements, in effect later this year.

icd-10 conversionOctober 1, 2015 came and we all survived. Most providers are finding that their claims are being paid. At MediTouch, we know our payer rejections and denial rates since the ICD-10 coding implementation have not significantly changed. Our First Pass Pay Rate has maintained its industry leading 98-99 percent average.

But …
We are in the honeymoon period. Remember, a few months prior to the start of ICD-10, CMS relaxed the claim submission standard (see our blog entitled Medicare ICD-10 Coding Flexibility – How It Works). Instead of requiring the precise code, CMS mandated that all Medicare claims should be paid as long as the code was in the code family that matched the clinical finding. Most commercial payers have been following Medicare’s lead.

The ICD-10 honeymoon period ends October 2016
Later this year, more precise coding of claims will be required. Many billing systems do not offer the additional tools to make the next leg of the ICD-10 transition work for your practice. There are three reasons that many billing systems will fail; in this blog we discuss one of those reasons.

GEMS alone doesn’t work
GEMS (General Equivalence Mappings) are cross-walks between the ICD-9 and ICD-10 coding system. The GEMS mapping is supplied by CMS at the following URL: https://www.cms.gov/medicare/coding/icd10/2015-icd-10-cm-and-gems.html

Providers are very familiar with the ICD-9 coding system, but not as familiar with the ICD-10 coding system, therefore many providers are still working off of ICD-9 codes and converting them to ICD-10. While thinking in terms of ICD-10 rather than ICD-9 is preferred, it will take a while for providers to have he same familiarity with ICD-10 as they do with ICD-9.

Currently many systems are using the GEMS mapping alone to assist providers in making the conversion. This may work well to match to the family of codes but it does not work well enough to get the level of specificity that could be required beginning this October.

In the above mentioned blog post, Medicare ICD-10 Coding Flexibility – How It Works, we examined the anatomy of an ICD-10 code for an Ankle Sprain. Now lets see if the GEMS mapping works perfectly for the different example.

Example: Decubitus Ulcer (heel)
Provider was using ICD-9 – 707.07 Decubitus Ulcer (heel) until October 2015

Using GEMS alone, the following ICD-10 codes match:

L89600 – Pressure ulcer of unspecified heel, unstageable
L89601 – Pressure ulcer of unspecified heel, stage 1
L89602 – Pressure ulcer of unspecified heel, stage 2
L89603 – Pressure ulcer of unspecified heel, stage 3
L89604 – Pressure ulcer of unspecified heel, stage 4
L89609 – Pressure ulcer of unspecified heel, unspecified stage

Lots of codes! But are they enough?
The above captioned codes L89600 – L89609 are certainly in the same family as the clinical condition of a Decubitus Ulcer of the heel.

But something is missing … You got it, lateralization, i.e. which side of the body is the affected heel located?

With simple GEMS mapping, there is no easy way to meet the very specific coding requirements that will be enforced later this year. This example is just one of thousands of instances where your ICD-10 coding system must be able to do more that just GEMS.

With MediTouch ICD-10 coding, a simple click on the appropriate stage will help you find the more specific code required to match the patient’s clinical condition to the most specific ICD-10 code.

Example: L89601 – Pressure ulcer of unspecified heel, stage 1 is the most appropriate GEMS match for the patient’s clinical condition but we need more codes to help us lateralize the code.

With MediTouch ICD-10 built-in coding tools, a simple click on the code will offer more suggestions:
L89611: Pressure ulcer of right heel, stage 1
L89621: Pressure ulcer of left heel, stage 1

Now the most specific code to describe the patient’s clinical condition is available and can be added to the claim.

Conclusion
If your current ICD-10 solution relies exclusively on GEMS mapping, this blog is proof that your system will fail later this year. In our next blog in this series we will discuss why tips regarding Code First and Exclusion Rules will be must haves later this year.