Researchers Link ICD-10 Shift to Financial Losses

John Commins, for HealthLeaders Media , March 17, 2014

HLM: Where are these losses coming from?

Neeta Venepalli

Andrew Boyd
Assistant Professor in Biomedical and Health Information Sciences at UIC

Boyd: We have three categories: An incorrect mapping, which is flat out wrong, too specific, where you get a whole lot more information, and too general. If you have more detail you can detect fraud. If it is too specific and a patient gets reassigned multiple codes by different clinicians on the oncology side, that could be picked up as fraud by the insurance companies.

You have more specificity, but there is disagreement about that and you get flagged as fraud. The goal is to be revenue neutral from the insurance companies, but with the increased specificity there are other concerns.

This 2.9% (reimbursements) and 5.3% (billing charges) are what you really have to be careful about. This information loss is critical because as a clinician you put down what is medically necessary or correct. But if it is an incorrect mapping and the insurance company maps it incorrectly to 10 and their algorithm to approve what gets reimbursed [may not get you] paid.

HLM: If you are identifying these issues with oncology, which you say is a relatively simple code set, what does this say about potential problems on Oct. 1 with more complex subspecialties?

Boyd: I'm not comfortable making predictions. Right now, appropriately, most of the training for physicians and coders is 'What are the 10 codes I need to memorize?' So, when you're looking at transitioning to ICD-10 the first thing you do is train everyone for the new codes. The first pass of training, just so you can collect money, is training on what the new codes are and what the new interface is.

As ICD-10 Deadline Looms, Providers Fret

What we are talking about in this translation tool and this new paper is that second analysis of these reports that the hospital or the outpatient clinic runs. Right now we are just trying to get through Door No. 1 before we get through Door No. 2. When you begin that second step we're saying here are some problems.

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2 comments on "Researchers Link ICD-10 Shift to Financial Losses"

Dan Toren (3/18/2014 at 2:32 PM)
Great questions Susie. From 3M website:"How 3M became the ICD-10 leader Under contract with the Centers for Medicare and Medicaid Services (CMS), 3M designed and developed the ICD-10 Procedure Coding System (ICD-10 PCS) and the General Equivalence Mappings (GEMs). 3M also completed the initial conversion of the CMS MS-DRGs to ICD-10." Disclaimer: we have nothing to do with 3M. However, anticipating the angst of October 1st, we've developed and recently released an app that may help alleviate the anxiety related to the ICD-10 implementation - ICD10Doc. And yes, we have actually used GEM for mapping between ICD-9 and ICD-10. is intended especially for the small practices that don't have the support or budgets of a hospital HIM department. You can check it out at Your feedback would be much appreciated Thanks Dan

Susie/Internal Medicine Practice Administrator (3/17/2014 at 10:54 AM)
I am still trying to figure out why there is the switch to ICD-10 in the first place. Real facts, not just government or insurance company public statements. Who wrote/created the GEMs? Is this evidence based medicine? When the author states that the maps may be wrong, most practices simply don't have the time or knowledge to create new algorithms. Is this tool for oncology only? Is this "map" ubiquitously used by Medicare and Commercial insurance companies? In other words, are they sharing the same GEMs? Any assistance would be greatly appreciated. Thank you in advance.




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