Transition to ICD-10 May Significantly Impact Pediatrician Practices

by | Published on Jul 7, 2014 | Medical Coding

Pediatrician Practices
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A recent study conducted at the University of Illinois, Chicago reports that pediatricians and other low margin practices may face a significant financial hit during the mandated conversion from the ICD-9 codes to the new ICD-10 codes. These specialists may lose money or data during the transition to ICD-10 medical codes. The results of this study were published in Pediatrics, the Journal of the American Academy of Pediatrics.

ICD medical codes are widely used in handling all significant aspects of healthcare starting from insurance reimbursements, staffing decisions, supply procurement and research. The ICD-10-CM codes are scheduled to be fully implemented on October 1, 2015. This new coding system includes more than 68,000 diagnostic codes when compared to the 14,000 ICD-9-CM codes.

Generally, pediatricians use a comprehensive range of ICD-9 codes relating to numerous categories such as infectious diseases, injury, childcare, and genetic disorders. As part of the study, the researchers utilized a conversion tool named GEMs (“general equivalent mappings”) for the conversion of codes. But it’s highly complex and difficult to interpret. In certain cases, some codes will get easily mapped to the new ones while others will have inconsistent mappings.

Researchers reviewed some of the commonly used codes, in order to analyze how the transition to the new code set is likely to affect the practice. They found that for patient encounters, payment and clinical data may get lost or overlapped in about 8% of these transitions. Moreover, ICD-10 implementation will cost around $83,000 and $2 million per practice, depending on the size.

Researchers used 2010 Illinois Medicaid data to identify ICD-9-CM codes for pediatric patients treated at the University of Illinois Hospital & Health Sciences System. They identified 2,708 ICD-9 codes used statewide and compared them with 174,500 Medicaid pediatric primary-care patient encounters and these encounters amounted to about $12.3 million in Medicaid payments. The medical codes conversion process was categorized (based on degree of complexity of the transition) into 5 different sections ranging from direct equivalent to convoluted. About 26% of the conversions were labeled as convoluted (as they included 23% of State Medicaid pediatric encounters and 16% of Medicaid reimbursements).

Medical practices may not get reimbursed and clinical data loss can happen if pediatricians use incorrect mappings. For example, the ICD-9 code for Twin, mate stillborn maps incorrectly to ICD-10 Twin liveborn.

  • ICD-9 code for “Twin, mate stillborn” – V38.30
  • ICD-10 code for “Twin liveborn” – Z38.30

Most of the pediatric practices perform on a low financial margin and are reimbursed at lower rates when compared to other specialties (especially by Medicaid). Hence, any discrepancies will considerably impact the functioning of these medical practices.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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