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ICD 10 – Effectiveness of Crosswalks

You’ve read about why ICD-9 to ICD-10 crosswalk is going to be needed during the dual processing period! You are probably also aware that any crosswalk will require additional data to be able to zero in on a single ICD-10 code corresponding to an ICD-9 code. So, what is this additional data? Where will you get the data from? Will whatever you are able get, be sufficient for effective crosswalk?

To answer the first question, even payers will need to look at the provider’s billing and coding department. That’s the place where the ICD codes are captured after an episode. Certified coders look at the physician’s notes, prescriptions and clinical documents to determine the ICD codes that need to be assigned to a claim. It’s not a straightforward job – the coders make it look simple, because they’re able to leverage their past experience. And even with experienced coders, there are errors… many of them.

Now you know more about the additional data you require to be able to map to ICD-10 codes accurately – you need all or significant part of the data that the coder at the hospital references to make that determination.

But where do you get that data from? The closest source you got is the PWK segment on the EDI file – that’s optional, but by enforcing that data in PWK be filled if the provider continues to send ICD-9 codes beyond compliance date, you MIGHT get some success.

5010 allows additional paperwork to be sent to the payer, by the provider’s office. For example, the administered drugs paperwork can be sent on a 5010. Also, on a 5010, the provider can indicate if there’s additional paperwork available at their office. Payers can request the additional paperwork if required to resolve crosswalk issue for a claim.

There are other details on the claim file that can also be utilized for this purpose (for example the provider type and specialty). Past data (like past claims for the member) and past experience in mapping similar ICD-9 codes can also be leveraged (just the way the coder at provider’s office will do it).

Will whatever additional information you are able to get be sufficient? Well, that’s what you got to find out. You don’t have to wait till the last minute. PWK segment is probably available on many of your current claims – so test it out. Find out how effective a crosswalk is.

Let me set the expectation right… any automated crosswalk is going to be only as effective. In some cases, the crosswalk might just limit the number of choices to select from – that’s where your staff will need to intervene and manually select the right code. The experience with manual intervention will constantly need to be fed back to the crosswalk to improve effectiveness.

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