ICD-10 Impact: Mitigating Risk with a Customizable Front-End Rules Engine

gearsAs the deadline for the ICD-10 transition fast approaches, we have been bombarded with an onslaught of information and strategies on how to navigate the change. However, little focus has been paid to how to manage this change using technology – specifically a customizable rules engine. ICD-10 is substantially more complex than ICD-9, and the two classification systems are so different, that a simple “crosswalk” is not possible. This poses a huge challenge for practices and coders alike. There are approximately 155,000 ICD-10 diagnosis and procedure codes, versus only about 24,000 ICD-9 codes.  To navigate through the sea of codes, practices need a customizable front-end rules engine that doesn’t simply scrub claims for coding but also uses forward mapping (translate ICD-9-CM codes into ICD-10-CM) and backward mapping (translate ICD-10-CM or PCS codes back into the ICD-9-CM format) to identify the “best ICD-10 code mix.” Practices should look for a revenue cycle management partner, like MDeverywhere, that can provide a customizable rules engine that includes crosswalk development, system remediation, dual coding, testing and even post go-live operational monitoring. With these systems in place, practices can automate the lower risk code sets, allowing physicians and coding staff to focus on the high risk codes – making sure entries are correct. This will allow your practice to ensure a revenue neutral conversion to ICD-10. Custom Rule Examples Below are few scenarios where customized rules can help prevent billing errors and subsequent denials: Hypertensive Chronic Kidney Disease: A diagnosis code from combination category I12, Hypertensive chronic kidney disease, should be used when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage chronic kidney disease.

  • Custom Rule #1: When both diagnosis codes i.e. I10 and N18 are present, rule will ask for I12 to be billed instead of two different codes.
  • Custom Rule #2: When diagnosis code from category I12 is used, rule will ask for a code from category N18 to be used as secondary code.

Hypertensive Heart and Chronic Kidney Disease: A diagnosis code from combination category I13, Hypertensive heart and chronic kidney disease, should be used when both hypertensive kidney disease I12 and hypertensive heart disease I11 are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. The appropriated code from category N18, chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease.

  • Custom Rule #3: When diagnosis codes from category I11 and I12 are present, rule will ask for code from category I13 to be billed instead of two different codes.
  • Custom Rule #4: When diagnosis code from category I13 is used, rule will ask for a code from category N18 to be used as secondary code.

Atherosclerosis with ulceration Atherosclerosis codes for category I70.23, I70.24, I70.33, I70.34, I70.43, I70.44, I70.53, I70.54, I70.63, I70.64, I70.73, I70.74 requires additional coded from category L97 to identify the severity of ulcer.

  • Custom Rule #5: When diagnosis from category I70.23, I70.24, I70.33, I70.34, I70.43, I70.44, I70.53, I70.54, I70.63, I70.64, I70.73, I70.74, is billed, rule will ask for a secondary code from category L97.

Stages of chronic kidney disease (CKD) and ESRD The ICD-10 CM classifies CKD based on severity. The severity of CKD is designated by stages 1-5 for which code from N18.1-N18.5 are used. For End Stage Renal Disease (ESRD) code N18.6 is used. If both a stage of CKD and ESRD are present, only ESRD diagnosis code N18.6 should be billed.

  • Custom Rule#6: When diagnosis codes N18.1, N18.2, N18.3, N18.4, N18.5 and N18.6 are used, rule will ask for to bill only diagnosis code N18.6.

Encounter for Delivery With delivery diagnosis O80 and O82 an additional code from category Z37 should be used to indicate the outcome of delivery.

  • Custom Rule# 7: When diagnosis O80 and O82 is billed and no code from category Z37 is present, the rule will ask to bill Z37.

Complications of pregnancy, childbirth and the puerperium: With diagnosis codes for complications of pregnancy, childbirth and puerperium (O00-O9A) an additional diagnosis code from category Z3A is required to indicate the weeks of gestation of the pregnancy.

  • Custom Rule#8: When a diagnosis from category (O00-O9A) is billed and no code from category Z3A is present, the rule will ask to bill code from category Z3A.

The scope of customizable rules creation for ICD-10 is wide open and waiting to be discovered as the industry progress towards ICD-10.  Make sure your practice is ready.

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