Transcript ICD-10 Overview - Puerto Rico Health Information Network

ICD-10 Overview
Program Integrity
Puerto Rico ICD-10
Implementation
Assistance Site Visit
Training Segments to assist Puerto Rico with
the ICD-10 transition
Mapping Best Practices
Code Structure & Definition
GEMS, Translation & Dual Processing
Managed Care Alignment
Claims Management
Provider Communication
Analytics & IT Infrastructure
ICD-10 Testing
Post Implementation Impacts &
Opportunities
Mapping & Policy Remediation
January 26-29, 2015
ICD-10 for Provider Offices
ICD-10 for Clinicians
Agenda

What is mapping and how is it different than
crosswalking?

Creating definitions of categories. Clearly defining
the intent.

Governance of the mapping process

Required resources

Pitfalls of the mapping process

Reusability and the single point of truth
1
The Two Sides of Translation
Translation between ICD-9 and ICD-10 involves two different
approaches.
1.
Creating Crosswalks
–
2.
Definitions for the conversion of one source code to one or
more target codes
Creating Equivalent Groups
–
Defining medical concepts that drive policies, rules, and
categorizations in ICD-10 that are consistent with the intent
of those policies, rules, and categorizations today
Source: Health Data Consulting 2011HResources
2
Mapping

A “Crosswalk” is the deliverable that answers the
question:
– If I need to replace an ICD-9 code with one or more ICD-10
code(s), which ICD-10 code(s) would best represent the
concepts that the original ICD-9 code intended to
represent?

An “Equivalent Group” is the deliverable that answers the
question:
– If I need to replace the original intent of a grouping of ICD9 codes with an equivalent grouping of ICD-10 codes,
which ICD-10 code set would best represent the original
intent of the group of ICD-9 codes?

“Mapping” is the process of arriving at both deliverables.
Source: Health Data Consulting 2013HResources
3
Intent
What am I trying to accomplish?

Analysis and data processing looks at some category
of conditions rather than one specific instance of a
condition.

Codes are grouped into categories for a variety of
analytic and processing purposes.

The intent is the reason the category is created.
Codes are grouped to that category based on the
defined intent of the creator.

Validation of codes within a category can only be
done if the intent is clear.
Source: Health Data Consulting 2013HResources
4
Concept
The key to proper mapping

The intent or definition of a category is based on the
inclusion or exclusion of a set concepts

Mapping of codes should be based on the degree to
which the code represents the intent or definition of
the category and the inclusion and exclusion criteria

Understanding the difference between “concepts”
and “words” or “code ranges” is critical to proper
mapping
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What’s a Concept?

A concept is a thought that we have in our brain

A term is a word in used in an expression (one of
many) that we might use to communicate concepts
to others.

A code is a ‘shorthand’ set of characters that may
represent one or more concepts.

Categories are high level concepts mapped to other
concepts for the purpose of organizing logical
groups. Concepts can be defined at any level of
detail.
6
Source: Health Data Consulting 2013HResources
Health Data Consulting © 2010
What’s a Concept?
The thought vs. the expression
“Doggie”
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Source:
Health Data Consulting 2013HResources
Health Data Consulting © 2010
Implied Concepts
Many expressions imply concepts that may not be explicitly
stated.
For example, the expression “Colle’s Fracture” implies the
following concepts:
 Radius
 Distal
 Extra-articular
 Volar angulation
 Bone
 Musculoskeletal System
 Injury
 Transverse
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Source:
Health Data Consulting 2013HResources
Health Data Consulting © 2010
Aliases and Overlapping Concepts
Many common medical expressions may include the same
concepts.
For example the following common medical expressions include
the concept of “Hypertension”:

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

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

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Benign Hypertension
Essential Hypertension
Familial Hypertension
Malignant Hypertension
Renal Hypertension
Pulmonary Hypertension
Portal Hypertension
Primary Hypertension
Secondary Hypertension
Borderline Hypertension
Source: Health Data Consulting 2013HResources










High Blood Pressure
Elevated Blood Pressure
HPB
Htn
Preeclampsia
Toxemia of Pregnancy
Hypertensive Crisis
180/100
Chronic Hypertension
Acute Hypertension
Health Data Consulting © 2010
Same Term, Different Concept
For example the term “had” could have
different meanings.
If Mary had a little lamb, did that
mean:
 She ate a small portion of lamb at the
restaurant?
 She gave birth to a baby lamb?
 She owned a small lamb?
10 Source: Health Data Consulting 2013HResources
Health Data Consulting © 2010
Aggregation and Granularity
Human
Compounds
Lipids
Minerals
Amino Acids
Alanine
Arginine
Cysteine
Proteins
Molecules
Sulfur
Hydrogen
Molecular
Parts
Carbon
Histidine
Nucleic Acid
Carbohydrates
Source: Health Data Consulting 2012HResourcesc
Proline
Tryptophan
Oxygen
Nitrogen
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The Code
What is it?

The code is simply an expression that is used in exchange
for a set of concepts suggested by another expression.
– “81341” vs “Closed Colle’s fracture”

The code is only meaningful to the degree that it conveys
concepts that can be consistently understood by users.

Codes and other expressions change, but the underlying
concepts don’t.

Concepts are the “Rosetta Stone” to which all codes,
words and other expressions are mapped
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Identifying Concepts
Clinical Scenario
A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s
fracture] on the [right] that was exposed through an [open
wound] with [minimal opening and minimal tissue damage]. The
fracture has [not healed after 6 months].
Though not explicitly stated in this scenario certain expressions
imply other concepts:
“Smith’s fracture” >> [fracture], [radius], [distal], [dorsal
angulation], [extra-articular], [displaced]
“minimal opening and minimal tissue damage” >> [Gustilo
classification I]
“not healed after 6 months” >> [nonunion]
Source: Health Data Consulting 2013HResources
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Source: Health Data Consulting 2013HResources
Defining Categories
Getting to the Intent
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A clear understanding of the intended purpose or
use of the category.
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A clear definition of the category.
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What are the concepts that the category is intended
to include?

What are the concepts that the category is intended
to exclude?
Source: Health Data Consulting 2013HResources
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Mapping
Governance
Agreeing to the intent as expressed in the definition
of the category requires governance and
concurrence.
 Transparency is critical to governance and clarity of
intent
 Issues and questions will be discovered during the
mapping process that require decisions
 Governance is not complete until there is validation
that the codes match the intent.

Source: Health Data Consulting 2013HResources
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Defining Intent
“Burn” Example
For the purpose of mapping codes to the category of
“Burns” the mapping team is charged with identifying
all codes related to “Burns”
 A preliminary definition of the category was:
–

“Damage to the body from heat related external causes”
Based on this definition the mapping team reviewed:
– The intended uses for this category
– The codes used today in ICD-9 to define this category
– Potential ICD-10 codes that might be used
Source: Health Data Consulting 2013HResources
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Defining Intent
“Burn” Example

The team identified a number of questions related to the definition
based on their initial review:
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Should chemical, radiation or other external causes be included?
Should sunburn be included?
Should Friction burns be included
Should internal burns to visceral organs be included?
Should assault or intentional self harm be included?
Should muscle calcification of other sequelae related to burns be
included?
Should external cause codes related to “burning” be included”
Managing issue or question resolution
Source: Health Data Consulting 2013HResources
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Defining Intent
“Burn” Example – Final Definition

Category definition (Burns_TPL):
– Damage to the body from external thermal or
chemical sources that may be related to a third party
cause.

Purpose:
– To identify claims where there may be a potential
third party liability for the condition of burns.
Source: Health Data Consulting 2013HResources
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Defining Intent
“Burn” Example – Final Definition

Includes:(Other than excluded below)
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Thermal related damage to any part of the body
Corrosive chemical damage to any part of the body
First degree burns
Burn related sequelae or complications if explicitly described as
related to the burn
Excludes: (all other codes not included)
–
–
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–
–
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Sunburn
Radiation related burns
Friction burns
Burns to internal visceral organs
Burns related to assault or intentional self harm
Burns related to complication of treatment
Source: Health Data Consulting 2013HResources
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Creating the Map
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The map should easily accessible and
understandable by all members of the team
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It should be defined in an easy to use format, but
one that can be easily converted to system readable
data
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Governance defines when the map is ready for
system incorporation

Governance must define the process of map updates
Source: Health Data Consulting 2013HResources
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Creating the Map
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The mapping document should include the following
metadata at a minimum:
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Date reviewed or updated
Validation status
Person or entity reviewing
Unique category name and level (lever1, level 2…)
Code type
Code
Code description
Mapping Comments
Mapping example
Source: Health Data Consulting 2013HResources
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Resources
This is not a one person effort
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Executive sponsorship  Coding professionals

Business analyst

System engineers

Clinicians


Policy creators and
managers
System configuration
specialists

QA specialists
Source: Health Data Consulting 2013HResources
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Resources
Using Resources Wisely
1. Decomplexification
2. Invite the right people to the
3.
4.
5.
6.
right meeting at the right time.
Respecting all input doesn’t
mean adopting it.
Don’t let history weigh you
down.
Get the job done; After listening
for a reasonable time, someone
needs to make a decision.
Sometimes less is better.
Source: Health Data Consulting 2013HResources
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Pitfalls of Mapping
 Unclear definition of intent
 Unclear definition of intent
 Unclear definition of intent
Source: Health Data Consulting 2013HResources
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Pitfalls of Mapping

Assumption that the codes used today are
correct

Introduction of new codes in ICD-10 where
the is no equivalent ICD-9 code

Inappropriate use of GEMS or other mapping
tools
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Improper use of term based queries
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Using ranges and making assumptions
Source: Health Data Consulting 2013HResources
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Pitfalls of Mapping

Operating on incomplete knowledge and
inadequate resources
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Lack of higher level commitment
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Lack of governance
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Inefficient or cumbersome processes

Not displaying code descriptions
Source: Health Data Consulting 2013HResources
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Policy Translation
Are the existing codes correct
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Evaluation of the original policy reveals a code definition error
– ‘73381’ – Malunion of fracture
– Translates to [2595] ICD-10 codes
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The policy allows treatment for any Navicular Fracture
– Native ICD-9 definition = [2] Codes
 GEM ICD-9 to ICD-10 = [2] codes (ICD-9 is the source code)
 GEM ICD-10 to ICD-9 = [42] codes (ICD-9 is the target code)
– Native ICD-10 definition = [126] Codes

Mapping of ICD-9 Procedure code
– ‘9986’ - Non-invasive placement of bone growth stimulator
– Translate to ‘3E00XGC’ - Introduction of other substance into skin and
mucous membranes, external approach
Source: Health Data Consulting 2013HResources
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Improper GEM Mapping
Fractures of the Radius

Native ICD-9 definition [33] Codes
[2 codes for Colles’ fracture]
[2 codes for Torus fracture of the Radius]
[1 codes for Pathologic fracture of the Radius]
[6 codes for fracture of the Forearm]
[22 codes for other fractures of the Radius]

GEM Bidirectional Map = [336]*
Source: Health Data Consulting 2013HResources
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Improper GEM Mapping
Fractures of the Radius
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Native ICD-10 definition [1818] Codes
[48 codes for Colles’ fracture]
[48 codes for Barton’s fracture]
[48 codes for Smith’s fracture]
[48 codes for Radial Styloid fracture]
[48 codes for Galeazzi’s fracture]
[36 codes for Torus fracture of the Radius]
[18 codes for Stress fracture of the Radius]
[18 codes for Greenstick fracture of the Radius]
[90 codes for Pathologic fracture of the Radius]
[45 codes for Bent Bone fracture of the Radius]
[216 codes for Growth Plate fracture of the Radius]
[663 codes for other fractures of the Radius]
Source: Health Data Consulting 2013HResources
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Improper Use of Terms
Fractures of the Proximal Femur

Assumption “Fractures of the Proximal Femur” include only
the terms:
–
“Fracture”
AND “Femur” (or “Femoral”)
AND “Proximal” ( or “upper ”)
[150] ICD-10 codes
Source: Health Data Consulting 2013HResources
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Improper use of Terms
Fractures of the Proximal Femur

“Fractures of the Proximal Femur” also includes:
–
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–
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“Intertrochanteric” + “fracture” [150]codes
“Subtrochanteric” + “fracture” [97]codes
“Neck” + “fracture” + “femur” [192]codes
“head” + “fracture” + “femur” [192]codes
“hip” + “fracture” [30]codes
Source: Health Data Consulting 2013HResources
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Mapping Steps
1. Clearly define the intent of the category
 Policy, rule, edit or other process
 Analysis (For what purpose?)
2. Identify the codes used today in ICD-9 to define that
category
3. Evaluate that the current codes are correct
 Were codes included that should not have been included
 Were code left out that should have been included
Source: Health Data Consulting 2013HResources
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Mapping Steps
4. Map current codes using GEM or other mapping
tool bidirectionally
5. Evaluate the mapping result to determine if codes
meet criteria for inclusion or exclusion
6. Query ICD-10 codes based on intended inclusion
concepts to see if other codes should be included
7. Validate the list of codes based on the category
definition and the inclusion and exclusion criteria
8. Establish the process for code mapping updates
Source: Health Data Consulting 2013HResources
34
State Medicaid Mapping Examples
Breast Reconstruction

The intent of this policy:
– Coverage for malignant neoplasms of the breast and
neoplasms of uncertain behavior
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Questions on mapping review:
–
–
–
Should all types of neoplasms be included?
Should this apply to male patients?
Should ‘personal history of’ or ‘encounter’ for breast
cancer be included?
Mapping example
Source: Health Data Consulting 2013HResources
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State Medicaid Mapping Examples
Bone Density
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The intent of this policy is to cover:
Thyrotoxicosis
Hyperparathyroidism (should include
hypothyroidism
Estrogen/testosterone deficiency
Ovarian failure
Osteomalacia / rickets
Hypo-calcemia
Amenorrhea
Osteoporosis
Pathologic fractures
Disorders of bone and cartilage
(unspecified)
Osteogenesis imperfect
Ehlers-Danlos Syndrome
Gonadal dysgenesis, Turner’s Syndrome
•
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•
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Marfan’s Syndrome
Fractures of the spine
Long-term use of glucocorticoid drugs
Drugs causing adverse effects in
therapeutic use
Menopausal Disorders
Long-term use (current) of other
medications
Following treatment with high-risk meds,
monitoring for response to osteoporosis
therapy
Following other treatment, for monitoring
ongoing therapy for osteoporosis
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State Medicaid Mapping Examples
Bone Density

Questions on mapping review:
– Based on the apparent intent of the code list, a number of codes
–
–
–
should be considered for addition
Descriptions of some of the codes were too vague and all
inclusive (Disorder of bone and cartilage, unspecified)
There were some invalid code listings that appear to represent
wildcards or categories of codes. These should be listed if that is
the case, or some wildcard indicator “%”or “*” to suggest that
this is a category and not a specific code
Substantial additional codes will be added on the ICD-10 side
Mapping Example
Source: Health Data Consulting 2013HResources
37
State Medicaid Mapping Examples
Hyperbaric Oxygen Therapy
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•
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•
•
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The intent of the policy is to cover:
Carbon Monoxide toxicity
Decompression illness
Gas embolism
Gas Gangrene
Acute traumatic peripheral
ischemia
• Crush injuries
• Limb Reattachment
• Necrotizing fasciitis
• Acute peripheral arterial
•
•
•
•
•
insufficiency
Certain skin grafts
Radiation necrosis
Cyanide Poisoning
Actinomycosis
Diabetic wounds
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State Medicaid Mapping Examples
Hyperbaric Oxygen Therapy
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The intent of the policy is to exclude:
Cutaneous, decubitus, and stasis ulcers
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Congenital conditions, such as cerebral palsy,
autism, mental retardation.
Chronic peripheral vascular insufficiency
•
Anaerobic septicemia and infection other than •
clostridial
•
Skin burns (thermal)
•
Senility
•
Myocardial infarction
•
Cardiogenic shock
•
Sickle cell anemia
•
Acute thermal and chemical pulmonary
•
damage, i.e., smoke inhalation with
•
pulmonary
•
insufficiency
•
Acute or chronic cerebral vascular insufficiency
Hepatic necrosis
Aerobic septicemia
Nonvascular causes of chronic brain syndrome
(Pick‘s Disease, Alzheimer‘s Disease,
Korsakoff‘s
Disease)
Tetanus
Systemic aerobic infection
Organ transplantation
Organ storage
Pulmonary emphysema
Exceptional blood loss anemia`
Multiple sclerosis
Arthritic disease
Acute cerebral edema
Mental retardation
Traumatic brain injury
Mapping Example
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Key Points

Mapping is a not mechanical or technical, it is the
applied science of informatics.

Creating categories or groups of codes requires a
clear definition based on a shared understanding of
the intent.

Code mapping is based on aligning concepts included
in those codes with the defined intent.

Governance of the mapping process is critical to
success.
Source: Health Data Consulting 2013HResources
40
Questions
41