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How will the MS-DRG ICD-10 Conversion Project affect your Practice?

September 30, 2013

what is the ms-drg ICD-10 conversion project?By now, your organization has probably begun or completed a training program for your staff in the new ICD-10 codes scheduled to replace the outdated ICD-9 system in October 2014. For many providers with Medicare patients, plenty of questions remain, including “What is the ‘MS-DRG ICD-10 Conversion Project’ and how can it affect my organization or practice?”

There have been white papers, articles, and other material in print and online either predicting something close to the Apocalypse, with provider’s payments drastically dropping, or showing little to no change altogether. The truth, as usual, is somewhere closer to the middle.

The ICD-10 Conversion Project is simply the process of converting previous diagnosis-related-groups (DRGs) to the new coding system. MS-DRG stands for Medicare Severity-Diagnosis Related Groups as its basis for payout to Medicare’s IPPS (inpatient prospective payment system). GEMs, or General Equivalence Mappings, are the means by which coders ‘translate’ from one code to the most appropriate translation in the other set of codes, either by ‘forward mapping’ (ICD-9 to ICD-10) or ‘backward mapping’ (from ICD-10 back to ICD-9). Because the two sets of codes are so different, the GEM data base was designed to assist in the conversion as a way to more easily locate and replace one code for another.

The goal of the CMS, according to Janice Bonazelli, one of the creators of the draft of the ICD-10 MS-DRG Definitions Manual was to enhance the conversion process with increased transparency, based on collection analysis of ICD-10 data from providers and other users. Because of this ongoing effort, which will continue for some time after the initial implementation, Bonazelli believes that providers and others will likely not see much change for at least the first year, until more data is available.

The available data also suggest that hospitals, in particular, may have benefited from the new changes. A recent 3M study of the proposed impact of conversion to ICD-10 on Medicare’s MS-DRG hospital payments found a small increase of 0.05 percent with ICD-10 coding of MS-DRGs. Conversely, mapping backward using General Equivalence Mappings (GEMs) from ICD-10 to ICD-9-CM and MS-DRGs resulted in a small decrease of 0.38 percent.

A Conversion Project PDF from the CMS website provides several examples of how these conversions work:

  • DRG385 Inflammatory bowel disease with MCC,

  • DRG386 Inflammatory bowel disease with CC

  • DRG38 Inflammatory bowel disease w/o CC/MCC

Four ICD-9 CM codes:

(Principal Diagnosis)

  • 555.0 Regional enteritis of the small intestine
  • 555.1 Regional enteritis of the large intestine
  • 555.2 Regional enteritis of the small intestine with large intestine
  • 555.9 Regional enteritis of an unspecified site

Replaced by 28 CM codes (partially listed here for the sake of brevity):

(Principal Diagnosis)

K5000 Crohn’s disease of the small intestine without complications

K50011 Crohn’s disease of the small intestine with rectal bleeding

K50012 Crohn’s disease of the small intestine with intestinal obstruction

K50013 Crohn’s disease of the small intestine with fistula

K50018 Crohn’s disease of the small intestine with other complication

K50019 Crohn’s disease of the small intestine with unspecified complications 

While not likely to be the hurdle to payments that some have predicted, any negative impact will more likely result from loss in productivity by staff during and after training, as well as an increase in denials from coding inaccuracies.

M-Scribe Technologies, LLC, a leader in medical reimbursement services, has been helping practices of all sizes work with the many challenges in coding and billing and documentation regulations. Contact their experienced counselors for assistance with your coding, billing or other reimbursement needs.


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