ICD- 10 Fine Print
Estimating Financial Impact
Many organizations are already feeling pressed to make ICD-
10 decisions without ICD- 10 data. This is especially true in the
interplay between providers and private sector payers, where
multiyear contracts up for renewal have much of their finan-
cial impact occurring in an ICD- 10 world. The temptation will
be great for stakeholders to speculatively propose and counter-
propose ICD- 10–based changes in the hope of benefitting their
organization or at least neutralizing a change perceived as a
disadvantage. During negotiations, each side will be desperate
to answer the question, “What will be the actual impact of the
ICD- 10 portion of this contract?”
This question is difficult to answer reliably without actual data
coded in ICD- 10. Ideally, an organization could obtain a dual-
coded record set for estimating financial impact by having cod-
ers code complete medical records in both ICD- 9 and ICD- 10
at the point of coding. Records coded directly in both code sets
will accurately reflect the detail available in the medical record
while working within the constraints of each classification.
If this option is not possible, the alternative is to convert historical ICD- 9 data to ICD- 10 data. However, to convert ICD- 9
data usefully to ICD- 10, the process must be sophisticated
enough so it is sensitive to both the whole ICD- 9 coded record
and the logic of the system being converted.
ICD- 9 data conversion for estimating ICD- 10 impact should
create a plausible ICD- 10 version of the ICD- 9 patient record.
For example, many codes in ICD- 9 do not specify anatomic site
or gender and their ICD- 10 counterparts do. By evaluating the
codes on the patient record as a whole, a context-sensitive con-
version from ICD- 9 to ICD- 10 can ensure that appropriate ana-
be made available, and the big print will claim they can do it all.
However, it is just as important to read the small print for data-
base conversions as for system conversions.
Financial Impact: An MS-DRG Case Study
A thorough and rigorous ICD- 10 financial impact requires five
conditions:
1. The system as it now operates using ICD-9-CM codes
2. A large, representative sample of ICD- 9 patient records
3. The same system converted to operate using ICD- 10 codes
4. The same sample of records converted to ICD- 10 by one of
two methods:
a. Records coded in both ICD- 9 and ICD- 10 by trained
coders
b. ICD- 9 records translated to ICD- 10 by computer, us-
ing a context-sensitive process
5. A program that yields the differences between the ICD- 9
and ICD- 10 systems in dollars
Creating “all-purpose” ICD- 10 records for general use in
estimating financial impact is a risky proposition at best.
tomic site or gender-specific codes are selected for the ICD- 10
version of the record.
Further, in order to create a correctly coded ICD- 10 version of
the ICD- 9 patient record, the ICD- 9 to ICD- 10 conversion process must accurately manage complex one-to-many and many-to-one relationships between ICD- 9 and ICD- 10 as well as adjust for differences in coding guidelines.
ICD- 9 data conversion for estimating ICD- 10 impact should
be done in the context of the system being converted. The appropriate ICD- 10 translation of a patient record depends on the
system being analyzed. A one-size-fits-all ICD- 9 to ICD- 10 data
conversion to create “all-purpose” ICD- 10 records for general
use in impact analysis is a risky proposition at best.
Mapping ICD- 9 data indiscriminately to ICD- 10 without sys-
tem-specific rules for selecting ICD- 10 codes injects a whole
new level of uncertainty into the original data. It decreases the
validity of the original ICD- 9 data and its reliability in impact
analyses. Generic database conversion programs will no doubt
Note that the ICD- 10 version of the system must replicate the
ICD- 9 version for the impact analysis to be valid.
Challenges and Opportunities
There is no escaping that ICD- 10 conversions must be done.
They require a lot of work, and they take planning, attention to
detail, persistence, and cooperation. But first they require that
organizations read the fine print about automation and commit
to doing the necessary review and validation.
To successfully transition to ICD- 10, organizations must understand where differences between ICD- 9 and ICD- 10 matter to them—from contract negotiations to documentation
requirements. HIM departments can use GEMs-based tools to
