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Study: Transition to ICD-10 May Cause Information, Financial Losses for Providers

Code ambiguity could mean problems with reimbursement

Health providers may experience information and financial loss during the mandated conversion from the current International Classification of Diseases (ICD) to its new and improved version, according to researchers at the University of Illinois at Chicago (UIC).

The study, published in the March issue of the Journal of Oncology Practice, looked at coding ambiguity for hematology–oncology diagnoses to anticipate challenges that all providers may face during the transition from ICD-9-CM to ICD-10-CM.

The researchers chose to look at hematology–oncology because previous research suggested that, compared with other subspecialties, it would have a simpler transition because of fewer ICD-10 codes and less convoluted mappings.

The nation’s health care system is scheduled to fully implement ICD-10 on October 1, and many doctors and hospitals are still preparing for the transition. The system is used to classify and code all diagnoses, symptoms, and procedures for reference in managing all aspects of health care — from insurance reimbursement to staffing decisions to supply procurement.

The ICD-10-CM includes more than 68,000 diagnostic codes, compared with 14,000 in ICD-9-CM. The Centers for Medicare and Medicaid Services provides a general equivalent mapping (GEM) code translation system, but it is complex and often difficult even for billers and coders to interpret, according to the researchers.

Codes often do not map one-to-one or one-to-many, said co-author Dr. Andrew Boyd. A cluster of codes might map to several ICD-10 codes, which might then map back to different ICD-9 codes, he said.

In the study, the researchers used 2010 Illinois Medicaid data to identify ICD-9-CM outpatient codes and the associated reimbursements used by hematology–"target=_blank>oncology physicians. The researchers identified 120 codes with the highest reimbursement for analysis.

They also looked at ICD-9-CM outpatient diagnosis codes and associated billing charges used by physicians at the UIC Cancer Center from 2010 to 2012 and selected the 100 most-used codes.

Using a web-based tool developed at UIC, the researchers input the ICD-9 codes and translated them into ICD-10 codes. They looked at whether the translation made sense; whether a loss of clinical information occurred; and whether a loss of information had financial implications.

“What we found was the transition from ICD-9 to ICD-10 led to significant information loss, affecting about 8% of the Medicaid codes and 1% of the codes in our cancer clinic,” said first author Dr. Neeta Venepalli.

In looking at the financial implications, the researchers found that 39 ICD-9-CM codes with information loss accounted for 2.9% of total Medicaid reimbursements and for 5.3% of UIC Cancer Center billing charges.

The report highlighted the 39 codes “to help identify that there might be trouble with reimbursement for these codes,” Boyd said.

Source: University of Illinois at Chicago; March 12, 2014.

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