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. 2014 Jul;134(1):31-6.
doi: 10.1542/peds.2013-4147. Epub 2014 Jun 2.

The transition to ICD-10-CM: challenges for pediatric practice

Rachel Caskey  1 , Jeffrey Zaman  2 , Hannah Nam  3 , Sae-Rom Chae  3 , Lauren Williams  4 , Gina Mathew  5 , Michael Burton  6 , Jiarong John Li  7 , Yves A Lussier  7 , Andrew D Boyd  8
Affiliations

The transition to ICD-10-CM: challenges for pediatric practice

Rachel Caskey et al. Pediatrics. 2014 Jul.

Abstract

Background and objectives: Diagnostic codes are used widely within health care for billing, quality assessment, and to measure clinical outcomes. The US health care system will transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), in October 2015. Little is known about how this transition will affect pediatric practices. The objective of this study was to examine how the transition to ICD-10-CM may result in ambiguity of clinical information and financial disruption for pediatricians.

Methods: Using a statewide data set from Illinois Medicaid specified for pediatricians, 2708 International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes were identified. Diagnosis codes were categorized into 1 of 5 categories: identity, class-to-subclass, subclass-to-class, convoluted, and no translation. The convoluted and high-cost diagnostic codes (n = 636) were analyzed for accuracy and categorized into "information loss," "overlapping categories," "inconsistent," and "consistent." Finally, reimbursement by Medicaid was calculated for each category.

Results: Twenty-six percent of pediatric diagnosis codes are convoluted, which represents 21% of Illinois Medicaid pediatric patient encounters and 16% of reimbursement. The diagnosis codes represented by information loss (3.6%), overlapping categories (3.2%), and inconsistent (1.2%) represent 8% of Medicaid pediatric reimbursement.

Conclusions: The potential for financial disruption and administrative errors from 8% of reimbursement diagnosis codes necessitates special attention to these codes in preparing for the transition to ICD-10-CM for pediatric practices.

Keywords: ICD-10-CM; ICD-9-CM; convolution; diagnostic codes; health informatics.

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Figures

FIGURE 1
FIGURE 1
Mapping complexity (A) and category (B) of diagnosis codes. Csect, C-section; Encntr, encounter; find, finding; Peds, pediatrics; Sexl, sexually; transmiss, transmission.
FIGURE 2
FIGURE 2
Evaluation categories: category examples for ICD-9-CM codes with convoluted mapping transitions to ICD-10-CM codes.
FIGURE 3
FIGURE 3
Percentage of patient visits and reimbursement associated with the coding categories.
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