ICD-10 Procedure Code

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					                                                                                                                     New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                Business Rules Comparison
                                                                                                                                 ICD-10 - Procedure Codes

#     Subsystem Current             New Business Rule                                        Level of Impact Description        Assumptions         Notes
                Business Rule                                                                Impact
                                                                                             on MMIS
1.0   All        There is no ICD    ACS will add an ICD version code column to the Claims        H    Anywhere there is a need
                 version code on    Header table so that OmniCaid downstream logic can                to distinguish between
                 the Claims         easily tell which ICD code format applies to the                  ICD-9 and ICD-10
                 Header Table.      diagnosis and ICD surgical/inpatient procedure codes              diagnosis or ICD
                                    on that claim. The ICD version indicator will be set to           surgical/inpatient
                                    ICD-9 for claims with LDOS (or discharge date, when               procedure code formats,
                                    present, for inpatient claims) prior to 10/1/2013, and            OmniCaid logic will be
                                    otherwise, to ICD-10.                                             modified to look at the
                                                                                                      claim ICD version code in
                                    CMS has stated that ICD-9 claims with LDOS (or                    order to decide the ICD
                                    discharge date when applicable) prior to 10/1/2013 are            format that should apply
                                    to be submitted with all ICD-9 format diagnosis and ICD-          to the logic.
                                    9 surgical procedure codes, and that claims with LDOS
                                    (or discharge date when applicable) on or after
                                    10/1/2013 are to be submitted with all ICD-10 format
                                    diagnosis and ICD-10 inpatient procedure codes. ICD-9
                                    and ICD-10 formats will not be mixed on a single claim.
                                    Therefore, throughout this document, we make
                                    reference to "ICD-10 claim" and "ICD-9 claim" which
                                    means the claim's DOS met the criteria described above
                                    for each, and that the diagnosis and ICD
                                    surgical/inpatient procedures codes share a common
                                    ICD format.




                                                            Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                        Page: 1 of 11                                                        November 30, 2009
                                                                                                                           New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                      Business Rules Comparison
                                                                                                                                       ICD-10 - Procedure Codes

#     Subsystem Current               New Business Rule                                        Level of Impact Description          Assumptions              Notes
                Business Rule                                                                  Impact
                                                                                               on MMIS
2.0   All        There is no          With ICD-10, there will be a need in a number of areas       H    New ICD code crosswalk      New business rules
                 current need to      for the capability to crosswalk ICD-10 codes back to a            tables and new              are based upon the
                 crosswalk            corresponding ICD-9 code(s), or to crosswalk ICD-9                crosswalking logic will     ACS recommendation
                 different versions   codes forward to the corresponding ICD-10 code(s).                need to be added at         that we use the CMS
                 of ICD-9 surgical                                                                      various points throughout   Reimbursement
                 procedure codes.                                                                       the system.                 Mapping Crosswalks
                                                                                                                                    as opposed to the
                                                                                                                                    General Equivalence
                                                                                                                                    Mapping (GEM)
                                                                                                                                    crosswalks.

                                                                                                                                    Arguments against
                                                                                                                                    the use of GEM
                                                                                                                                    mapping include the
                                                                                                                                    following:
                                                                                                                                    1) Multiple scenarios
                                                                                                                                    are present for most
                                                                                                                                    codes, which would
                                                                                                                                    require an analysis of
                                                                                                                                    the patient records to
                                                                                                                                    determine the best
                                                                                                                                    scenario, and
                                                                                                                                    2) Would necessitate
                                                                                                                                    manual processing of
                                                                                                                                    some claims, or
                                                                                                                                    would require
                                                                                                                                    automated
                                                                                                                                    assumption of which
                                                                                                                                    scenario to use.




                                                                Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                            Page: 2 of 11                                                          November 30, 2009
                                                                                                                          New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                     Business Rules Comparison
                                                                                                                                      ICD-10 - Procedure Codes

#     Subsystem Current             New Business Rule                                        Level of Impact Description            Assumptions         Notes
                Business Rule                                                                Impact
                                                                                             on MMIS
3.0   All        Current field    No field length change is necessary to accommodate             N    n/a
                 length is 7      ICD-10. ICD-10 inpatient procedure length is a constant
                 characters.      length of 7 characters. There is no longer a decimal
                                  point.
4.0   Claims     OmniCaid claims OmniCaid claims entry/correction will use header LDOS          H     Modify OmniCaid claims
                 entry/correction (or discharge date when applicable) to determine                    adjudication engine to
                 assumes ICD-9 whether the claim ICD version code should be set to                    base ICD
                 surgical         ICD-9 or ICD-10 and whether ICD surgical/inpatient                  surgical/inpatient
                 procedure codes. procedure codes entered should be in ICD-9 or ICD-10                procedure edits on claim
                                  format.                                                             LDOS throughout.

                                                                                                      Review ICD
                                                                                                      surgical/inpatient
                                                                                                      procedure edit
                                                                                                      descriptions and
                                                                                                      resolution instructions for
                                                                                                      explicit references to ICD-
                                                                                                      9 and change them to
                                                                                                      ICD.

5.0   Claims     OmniCaid COS       OmniCaid COS determination logic will use either ICD-9      H     Forward conversion of
                 determination      or ICD-10 inpatient procedure codes to determine                  existing ICD-9 surgical
                 logic uses ICD-9   whether COS should be Family Planning based on the                procedure codes to their
                 surgical           claim's ICD version code.                                         ICD-10 equivalent(s) will
                 procedure codes                                                                      use the same reference
                 to determine                                                                         table indicators (including
                 whether COS                                                                          family planning indicator)
                 should be Family                                                                     on the ICD-10 version of
                 Planning.                                                                            the codes. May need
                                                                                                      input from MAD in cases
                                                                                                      where the ICD-9 code
                                                                                                      has multiple choices for
                                                                                                      ICD-10 equivalent codes.




                                                             Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                         Page: 3 of 11                                                           November 30, 2009
                                                                                                                          New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                     Business Rules Comparison
                                                                                                                                      ICD-10 - Procedure Codes

#     Subsystem Current             New Business Rule                                    Level of Impact Description               Assumptions         Notes
                Business Rule                                                            Impact
                                                                                         on MMIS
6.0   Claims     DRG pricing     CMS has indicated that it expects the ICD-10 DRG            H    Logic will be added to
                 logic uses use  grouper to be ready by the implementation date. DRG              DRG pricing so that
                 ICD-9 format    pricing for ICD-9 claims will continue to use ICD-9              claims will use the
                 inpatient       format input for grouper. DRG pricing for ICD-10 claims          version of the DRG
                 procedure codes will use ICD-10 format input for grouper.                        grouper appropriate for
                 as input for                                                                     their ICD format.
                 grouper.
7.0   Claims     OmniCaid cost      OmniCaid cost center assignment logic will use either       H    May need input from
                 center             ICD-9 or ICD-10 inpatient procedure codes to determine           MAD during forward
                 assignment logic   how to populate the Family Planning cost center based            conversion for cases
                 uses ICD-9         on the claim's ICD version code.                                 where the ICD-9 code
                 surgical                                                                            has multiple choices for
                 procedure codes                                                                     ICD-10 equivalent codes.
                 to determine
                 how to populate
                 the Family
                 Planning cost
                 center.


8.0   Claims     OmniCaid claims    OmniCaid claims history profile request will allow only     H    PowerBuilder claims
                 history profile    ICD-10 format inpatient procedure codes for use as               history profile entry edits
                 request allows     selection criteria. The history profile selection process        will need to be modified.
                 entry of ICD-9     will use the history claim's ICD version code to
                 surgical           determine whether it needs to backward convert ICD-10
                 procedure codes.   format selection criteria to its ICD-9 equivalent for
                                    comparison purposes during the history profile selection
                                    process.




                                                               Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                           Page: 4 of 11                                                        November 30, 2009
                                                                                                                          New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                     Business Rules Comparison
                                                                                                                                      ICD-10 - Procedure Codes

#     Subsystem Current             New Business Rule                                          Level of Impact Description         Assumptions         Notes
                Business Rule                                                                  Impact
                                                                                               on MMIS
8.1   Claims     Claims client     OmniCaid will use claim ICD version code and list              M     All existing list entries
                 EOMB claim        effective dates to pick the correct list entries for                 with ICD-9 procedure
                 selection         excluding claims from EOMB selection.                                codes will be ended as of
                 excludes claims                                                                        9/30/2010. ICD-9 to ICD-
                 with certain ICD-                                                                      10 crosswalk will need to
                 9 procedure                                                                            be used to create new list
                 codes using a                                                                          entries with equivalent
                 system list.                                                                           ICD-10 procedure codes
                                                                                                        and effective date
                                                                                                        10/1/2013.


9.0   Data      CMS-64 uses a       CMS-64 will use an ICD-9 or ICD-10 format list of family      M     May need input from
      Warehouse list of family      planning inpatient procedure codes when determining                 MAD during forward
                planning ICD-9      whether to split out the family planning reimbursement              conversion for cases
                surgical            amount on claim lines depending on the claim's ICD                  where the ICD-9 code
                procedure codes     version code.                                                       has multiple choices for
                when                                                                                    ICD-10 equivalent codes.
                determining
                whether to split
                out the family
                planning
                reimbursement
                amount on claim
                lines.




                                                               Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                           Page: 5 of 11                                                        November 30, 2009
                                                                                                                        New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                   Business Rules Comparison
                                                                                                                                    ICD-10 - Procedure Codes

#    Subsystem Current              New Business Rule                                       Level of Impact Description           Assumptions         Notes
               Business Rule                                                                Impact
                                                                                            on MMIS
10.0 General     OmniCaid        OmniCaid will use claim ICD version code and list             M     All existing list entries
                 system lists of effective dates to pick the correct list entries for edits          with ICD-9 surgical
                 surgical        that use system lists of ICD surgical/inpatient procedure           procedure codes will be
                 procedure codes codes.                                                              ended as of 9/30/2010.
                 used in various                                                                     ICD-9 to ICD-10
                 edits assume                                                                        crosswalk will need to be
                 ICD-9 format.                                                                       used to create new list
                                                                                                     entries with equivalent
                                                                                                     ICD-10 inpatient
                                                                                                     procedure codes and
                                                                                                     effective date 10/1/2013.


11.0 Managed     MC plans allows    MC plans allows the use of a system list of ICD            M     Conversion - Existing ICD-
     Care        the uses of a      surgical/inpatient procedure code ranges to show                 9 surgical procedure list
                 system list of     services excluded from the plan. Edits will the claim's          entries, if any, will be
                 ICD-9 surgical     ICD version code to determine which system list span             ended 9/30/2013. New
                 procedure code     (and therefore which ICD version code) applies.                  entries will be created
                 ranges to show                                                                      with ICD-10 equivalent
                 services                                                                            codes effective 10/1/2013.
                 excluded from
                 the plan.




                                                               Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                           Page: 6 of 11                                                       November 30, 2009
                                                                                                                         New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                    Business Rules Comparison
                                                                                                                                     ICD-10 - Procedure Codes

#   Subsystem Current              New Business Rule                                         Level of Impact Description            Assumptions         Notes
              Business Rule                                                                  Impact
                                                                                             on MMIS
12.0 MARS       ICD-9 surgical     MARS subsystem was not remediated during the                 MI    Possible Impact:
                procedure code     original HIPAA project. The ICD-9 codes used in MARS               1) M - Backward
                length is 5        are defined as 5 characters. ICD-10 remediation                    conversion for MARS
                characters long    options:
                                                                                                      already exists.
                throughout         1) Ongoing backward conversion of ICD-10 codes
                                                                                                      Enhance it to backward
                MARS               using the CMS Reimbursement Mapping Crosswalk as
                subsystem.         part of monthly MARS processing                                    convert ICD-10 codes
                                   2) Replace MARS with a third party E-MARS solution                 to ICD-9.
                                   before October 2013                                                2) H - Build multiple
                                   3) Change length of fields throughout MARS subsystem               MMIS data interfaces
                                                                                                      for third party solution
                                                                                                      3) H - Remediate
                                                                                                      existing MARS
                                                                                                      subsystem to
                                                                                                      accommodate ICD-10
                                                                                                      codes - not
                                                                                                      recommended -
                                                                                                      system is 20+ years old

13.0 OCR        OCR third party    OCR third party software will need to validate that all      M     New logic for both ICD-9
                software only      ICD procedure codes on the claim are in either ICD-9 or            and ICD-10 procedure
                validates ICD-9    ICD-10 format based on the claim's LDOS.                           code format validation will
                surgical                                                                              need to be developed.
                procedure code
                format.
14.0 OCR        OCR claims         All ICD-10 inpatient procedure codes will be 7               H     Add R_ICD_VER_CD to
                preprocessors      characters long. The only validation necessary is                  the Reference ICD
                only validate ICD- whether the code exists on the Reference database.                 procedure code database
                9 surgical                                                                            to facilitate ICD-10 code
                procedure code                                                                        validation.
                formats.




                                                             Appendix A.8.2 - ICD-10 Procedures Code
Worksheet: ICD-10 Procedure Code                                          Page: 7 of 11                                                           November 30, 2009
                                                                                                                           New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                      Business Rules Comparison
                                                                                                                                       ICD-10 - Procedure Codes

#    Subsystem Current              New Business Rule                                         Level of Impact Description           Assumptions              Notes
               Business Rule                                                                  Impact
                                                                                              on MMIS
15.0 PA          Prior              OmniCaid PA Detail edits will allow only ICD-9 format         H    OmniCaid PA edits will       There are currently no
                 Authorization      surgical procedure codes to be entered on lines with               use claim's ICD version      PA's on the database
                 allows             LDOS before 10/1/2013, and only ICD-10 format                      code to determine if ICD-    that use the ICD-9
                 specification of   inpatient procedure codes on lines with LDOS after that            10 code on the PA needs      procedure code line
                 ICD-9 surgical     date.                                                              to be backward converted     item service type
                 procedure code                                                                        to ICD-9 for comparison      code.
                 for line item                                                                         purposes.
                 service type.

16.0 Provider    OmniCaid           OmniCaid Provider Detail Review tab will not allow            H     All existing list entries
                 Provider Detail    review span which include diagnosis codes to straddle               with ICD-9 surgical
                 Review tab         the ICD-10 implementation date. Only ICD-9 surgical                 procedure codes will be
                 allows providers   procedure codes will be allowed before that date, only              ended as of 9/30/2010.
                 to be put on       ICD-10 inpatient procedure codes on or after that date.             ICD-9 to ICD-10
                 review for a                                                                           crosswalk will need to be
                 single ICD-9                                                                           used to create new list
                 surgical                                                                               entries with equivalent
                 procedure or                                                                           ICD-10 inpatient
                 range of ICD-9                                                                         procedure codes and
                 surgical                                                                               effective date 10/1/2013.
                 procedures.
17.0 Reference   Reference          An ICD version code column will be added to Reference         H     Logic to check for either
                 subsystem ICD      subsystem ICD surgical/inpatient procedure tables to                ICD-10 or ICD-9 version
                 surgical           allow system to distinguish between ICD-9 and ICD-10                may need to be added to
                 procedure tables   formats.                                                            every query against these
                 assume ICD-9                                                                           tables to retrieve the
                 format.                                                                                desired data. It must be
                                                                                                        added in all cases where
                                                                                                        the query is looking for
                                                                                                        codes that apply to a
                                                                                                        specific claim DOS.




                                                              Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                          Page: 8 of 11                                                            November 30, 2009
                                                                                                                      New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                 Business Rules Comparison
                                                                                                                                  ICD-10 - Procedure Codes

#    Subsystem Current              New Business Rule                                      Level of Impact Description          Assumptions         Notes
               Business Rule                                                               Impact
                                                                                           on MMIS
18.0 Reference   OmniCaid         An ICD version code selection capability will be added       H    ICD version selection
                 Reference        to the OmniCaid Reference windows to enable users to              option added to search
                 windows assume select either ICD-9 or ICD-10 codes or both. "Both"                 windows that allow ICD
                 ICD-9 surgical   format option will be disallowed when the user is adding          surgical/inpatient
                 procedure codes. a new ICD-10 inpatient procedure code.                            procedure code entry.

                                                                                                    Modified data window
                                                                                                    queries to return codes
                                                                                                    based on user's ICD
                                                                                                    version selection
19.0 Reference   OmniCaid         OmniCaid ICD surgical/inpatient procedure code format      H      New PowerBuilder ICD
                 application      edits will be enforced based upon the ICD version                 inpatient procedure edit
                 enforces         entered by the user.                                              function for ICD-10 based
                 formatting rules                                                                   on user entered ICD
                 for ICD-9                                                                          version code.
                 surgical
                 procedure codes.

20.0 Reference   Annual             OmniCaid ICD surgical/inpatient procedure code format    H      New PowerBuilder ICD
                 diagnosis and      edits will be enforced based upon the ICD version               inpatient procedure edit
                 ICD-9 surgical     entered by the user.                                            function for ICD-10 based
                 procedure code                                                                     on user entered ICD
                 updates require                                                                    version code.
                 manual
                 intervention.




                                                             Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                         Page: 9 of 11                                                       November 30, 2009
                                                                                                                     New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                Business Rules Comparison
                                                                                                                                 ICD-10 - Procedure Codes

#    Subsystem Current              New Business Rule                                   Level of Impact Description          Assumptions         Notes
               Business Rule                                                            Impact
                                                                                        on MMIS
21.0 Reference   Existing ICD-9     Need an automated load and conversion process for       H    ACS will use CMS data
                 surgical           new ICD-10 inpatient procedure codes.                        files as the basis for
                 procedure codes                                                                 loading the new ICD-10
                 are only valid for                                                              inpatient procedure
                 DOS prior to                                                                    codes. Once the codes
                 10/1/2013.                                                                      are loaded, we will use
                                                                                                 the CMS reimbursement
                                                                                                 mapping crosswalk to
                                                                                                 backward convert the
                                                                                                 new ICD-10 to its ICD-9
                                                                                                 equivalent so that we can
                                                                                                 use the ICD-9 diagnosis
                                                                                                 indicators as the basis for
                                                                                                 the initial setting of the
                                                                                                 indicators on the
                                                                                                 corresponding ICD-10
                                                                                                 code(s).



22.0 Reference   Existing ICD-9   Due to the expected increase in the volume of new         MI    Meet with stakeholders to
                 surgical         codes for ICD-10, we highly recommend additional                determine the feasibility
                 procedure code automation of the annual update process.                          of additional automation
                 update process                                                                   of the ICD-10 code
                 relies on manual                                                                 annual update process.
                 intervention.
                                                                                                  Determine new default
                                                                                                  equivalent codes for
                                                                                                  setting indicators on the
                                                                                                  inpatient procedure code
                                                                                                  table.




                                                            Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                        Page: 10 of 11                                                    November 30, 2009
                                                                                                                        New Mexico MMIS HIPAA 2 Assessment
                                                                                                                                   Business Rules Comparison
                                                                                                                                    ICD-10 - Procedure Codes

#    Subsystem Current              New Business Rule                                         Level of Impact Description       Assumptions          Notes
               Business Rule                                                                  Impact
                                                                                              on MMIS
23.0 Web Portal   Web portal EHR Web portal EHR inquiry will allow input ICD-9 surgical           H    Modify web portal EHR
                  inquiry allows  procedure codes in ICD-9, ICD-10 or either ICD-9 or                  inquiry to allow input
                  input ICD-9     ICD-10 format depending on the inquiry DOS range.                    surgical procedure codes
                  surgical                                                                             in ICD-9 format only if
                  procedure codes                                                                      DOS range ends prior to
                  in ICD-9 format                                                                      10/1/2013 or ICD-10
                  only.                                                                                format if DOS range
                                                                                                       overlaps 10/1/2013 or no
                                                                                                       DOS range is entered.
                                                                                                       Backward convert ICD-10
                                                                                                       codes to ICD-9 for
                                                                                                       selection purposes on
                                                                                                       ICD-9 format claims.


24.0 Web Portal   Web portal       Web portal Claim Status Inquiry detail will display both      M     Modify web portal Claim
                  Claim Status     ICD-9 and ICD-10 format inpatient procedure codes                   Status inquiry detail
                  inquiry detail   depending on the claim's ICD version.                               display to accommodate
                  displays assume                                                                      both ICD-9 and ICD-10
                  ICD-9 format                                                                         codes.
                  surgical
                  procedure codes.



                                                                                                       L (Low) = 0 to 16 hours
                                                                                                       M (Medium) = 17 to 40 hours
                                                                                                       H (High) = 40+ hours
                                                                                                       N (None) = No Impact on MMIS
                                                                                                       FA (Further Analysis) = Further Analysis Needed
                                                                                                       MI (MAD Input) = MAD input needed




                                                               Appendix A.8.2 - ICD-10 Procedures Code
 Worksheet: ICD-10 Procedure Code                                           Page: 11 of 11                                                     November 30, 2009

				
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