11 - Appendix A.8.1 - ICD-10 Diag Code BRC (11-24-2009)

New Mexico MMIS HIPAA 2 AssessmentBusiness Rules Comparison

ICD-10 - Diagnosis Code

Worksheet: ICD-10 Diagnosis Code Appendix A.8.1 - ICD-10 Diagnosis CodePage: 1 of 16

November 30, 2009

# Subsystem New Business Rule Impact Description Assumptions Notes

1.0 All H

Current Business Rule

Level of Impact on MMIS

There is no ICD version code on the Claims Header Table.

ACS will add an ICD version code column to the Claims Header table so that OmniCaid downstream logic can easily tell which ICD code format applies to the diagnosis and ICD surgical/inpatient procedure codes on that claim. The ICD version indicator will be set to ICD-9 for claims with LDOS (or discharge date, when present, for inpatient claims) prior to 10/1/2013, and otherwise, to ICD-10.

CMS has stated that ICD-9 claims with LDOS (or discharge date when applicable) prior to 10/1/2013 are to be submitted with all ICD-9 format diagnosis and ICD-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.

Anywhere there is a need to distinguish between ICD-9 and ICD-10 diagnosis or ICD surgical/inpatient procedure code formats, OmniCaid logic will be modified to look at the claim ICD version code in order to decide the ICD format that should apply to the logic.




November 30, 2009

# Subsystem New Business Rule Impact Description Assumptions NotesCurrent Business Rule


2.0 All HThere is no current need to crosswalk different versions of ICD diagnosis codes.

With ICD-10, there will be a need in a number of areas (Claims UR, special logic based on hard-coded diagnosis code ranges, etc.) for the capability to crosswalk ICD-10 codes back to a corresponding ICD-9 code(s), or to crosswalk ICD-9 codes forward to the corresponding ICD-10 code(s).

New ICD code crosswalk tables and new crosswalking logic will need to be added at various points throughout the system.

New business rules are based upon the ACS recommendation that we use the CMS Reimbursement 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, and2) Would necessitate manual processing of some claims, or would require automated assumption of which scenario to use.




November 30, 2009



3.0 Claims H

4.0 Claims H

OmniCaid claims entry/correction assumes ICD-9 diagnosis codes.

OmniCaid claims entry/correction will use header LDOS (or discharge date when applicable) to determine whether the claim ICD version code should be set to ICD-9 or ICD-10 and whether diagnosis codes entered should be in ICD-9 or ICD-10 format.

Modify OmniCaid claims adjudication engine to base diagnosis edits on claim R_ICD_VER_CD throughout.

Review diagnosis edit descriptions and resolution instructions for explicit references to ICD-9 and change them to ICD.

OmniCaid COS determination logic uses ICD-9 diagnosis codes to determine whether COS should be Family Planning.

OmniCaid COS determination logic will use either ICD-9 or ICD-10 diagnosis codes to determine whether COS should be Family Planning based on the claim's ICD version code.

Forward conversion of existing ICD-9 diagnosis codes to their ICD-10 equivalent(s) will use the same reference table indicators (including family planning indicator) on the ICD-10 version of the codes. May need input from MAD in cases where the ICD-9 code has multiple choices for ICD-10 equivalent codes.




November 30, 2009



5.0 Claims H

6.0 Claims H

DRG pricing logic uses use ICD-9 format diagnosis codes as input for grouper.

CMS has indicated that it expects the ICD-10 DRG grouper to be ready by the implementation date. DRG pricing for ICD-9 claims will continue to use ICD-9 format input for grouper. DRG pricing for ICD-10 claims will use ICD-10 format input for grouper.

Logic will be added to DRG pricing so that claims will use the version of the DRG grouper appropriate for their ICD format.

Claims UR medical criteria can include/exclude a range or a list of ranges of ICD-9 diagnosis codes.

There are currently no diagnosis ranges or lists associated with Claims Utilization Review (UR) Medical criteria records. ACS will convert existing UR medical criteria diagnosis codes to ICD-10 format. Whenever an in process claim is an ICD-9 claim, UR edit logic will use the CMS Reimbursement mapping crosswalk to backward convert any ICD-10 diagnosis codes associated with the medical criteria to their ICD-9 equivalent code in order to determine whether the criteria applies to the in process claim.

ICD-10 to ICD-9 reimbursement crosswalk logic will need to be factored into diagnosis related edits that involve historical claim data.




November 30, 2009



7.0 Claims H

8.0 Claims H

Claims UR medical limit parameters can include/exclude a range or a list of ranges of ICD-9 diagnosis codes.

There are currently only 3 diagnosis code ranges and no lists associated with UR Medical limit parameters. ACS will convert existing UR limit parameter diagnosis codes to ICD-10 format. Whenever an in process or history claim is an ICD-9 claim, UR edit logic will use the CMS Reimbursement mapping crosswalk to backward convert any ICD-10 diagnosis codes associated with the medical criteria to their ICD-9 equivalent code in order to determine whether the criteria applies to the in process claim.


Claims UR medical contraindicated parameters can include/exclude claims based on whether their ICD-9 diagnosis codes are the same or different.

There are currently no contraindicated parameters that apply the same/different diagnosis logic. If the in process claim is an ICD-10 claim and the history claim is an ICD-9 claim, OmniCaid will backward convert the codes on the ICD-10 in process claim to their ICD-9 equivalent code prior to comparison with the history claim.





November 30, 2009



9.0 Claims H

10.0 Claims H

OmniCaid cost center assignment logic uses ICD-9 diagnosis codes to determine how to populate the Family Planning cost center.

OmniCaid cost center assignment logic will use either ICD-9 or ICD-10 diagnosis codes to determine how to populate the Family Planning cost center based on the claim's ICD version code.

Diagnosis code hold areas in the cost center assignment module need to be expanded to 10 characters to match the length used elsewhere in the system. This will accommodate ICD-10 codes.

May need input from MAD during forward conversion for cases where the ICD-9 code has multiple choices for ICD-10 equivalent codes.

OmniCaid claims history profile request allows entry of ICD-9 diagnosis codes.

OmniCaid claims history profile request will allow only ICD-10 format diagnosis codes for use as selection criteria. The history profile selection process will use the history claim's ICD version code to determine whether it needs to backward convert ICD-10 format selection criteria to its ICD-9 equivalent for comparison purposes during the history profile selection process.

PowerBuilder claims history profile entry edits will need to be modified.




November 30, 2009



10.1 Claims M

11.0 M

12.0 EMC H

Claims client EOMB claim selection excludes claims with certain diagnosis codes using a system list.

OmniCaid will use claim ICD version code and list effective dates to pick the correct list entries for excluding claims from EOMB selection.

All existing list entries with ICD-9 diagnosis codes will be ended as of 9/30/2010. ICD-9 to ICD-10 crosswalk will need to be used to create new list entries with equivalent ICD-10 diagnosis codes and effective date 10/1/2013.

Data Warehouse

CMS-64 uses a list of family planning diagnosis codes when determining whether to split out the family planning reimbursement amount on claim lines.

CMS-64 will use an ICD-9 or ICD-10 format list of family planning diagnosis codes when determining whether to split out the family planning reimbursement amount on claim lines depending on the claim's ICD version code.

May need input from MAD during forward conversion for cases where the ICD-9 code has multiple choices for ICD-10 equivalent codes.

EMC claims preprocessors only validate ICD-9 diagnosis code formats.

EMC claims preprocessors will validate ICD-9 and ICD-10 diagnosis code formats depending the on claim's ICD version indicator.

New logic for ICD-10 diagnosis code format validation will need to be developed.




November 30, 2009



13.0 EPSDT M

14.0 EPSDT M

EPSDT Detail update process uses various diagnosis codes for comparisons and setting of various indicators that determine whether and how claim should be reflected in the EPSDT database.

EPSDT Detail update process will use the ICD version code on the claim to determine when it should use ICD-10 or ICD-9 diagnosis codes for comparisons and setting of various indicators that determine whether and how claim should be reflected in the EPSDT database.

Will need to crosswalk the existing ICD-9 diagnosis codes to their ICD-10 equivalent(s) and add logic to use the ICD version code on the claim to determine which format to compare.

EPSDT CMS 416 Report uses various diagnosis codes to determine whether a claim should be counted as a blood lead screening.

EPSDT CMS 416 Report will use the ICD version code on the claim to determine when it should use ICD-10 or ICD-9 diagnosis codes to determine whether a claim should be counted as a blood lead screening.





November 30, 2009



15.0 Financial M

16.0 General M

Accounting Claim transaction COS determination logic uses ICD-9 diagnosis codes to determine whether COS on the transaction file should be set to EPSDT.

OmniCaid COS determination logic will use either ICD-9 or ICD-10 diagnosis codes to determine whether COS on the transaction file should be set to EPSDT based on the claim's ICD version code.

Forward conversion of existing ICD-9 diagnosis codes to their ICD-10 equivalent(s) will need to be done. May need input from MAD in cases where the ICD-9 code has multiple choices for ICD-10 equivalent codes.

OmniCaid system lists of diagnosis codes used in various edits assume ICD-9 format.

OmniCaid will use claim ICD version code and list effective dates to pick the correct list entries for edits that use system lists of diagnosis codes.





November 30, 2009



17.0 Managed Care M

18.0 MARS MI

MC plans allows the uses of a system list of diagnosis code ranges to show services excluded from the plan.

MC plans allows the use of a system list of diagnosis code ranges to show services excluded from the plan. Edits will the claim's ICD version code to determine which system list span (and therefore which ICD version code) applies.

Conversion - Existing diagnosis list entries, if any, will be ended 9/30/2013. New entries will be created with ICD-10 equivalent codes effective 10/1/2013.

Diagnosis code length is 5 characters long throughout MARS subsystem.

MARS subsystem was not remediated during the original HIPAA project. The ICD-9 codes used in MARS are defined as 5 characters. ICD-10 remediation options:1) Ongoing backward conversion of ICD-10 codes using the CMS Reimbursement Mapping Crosswalk as part of monthly MARS processing2) Replace MARS with a third party E-MARS solution before October 20133) Change length of fields throughout MARS subsystem

Possible Impact:1) M - Backward conversion for MARS already exists. Enhance it to backward convert ICD-10 codes to ICD-9.2) H - Build multiple MMIS data interfaces for third party solution3) H - Remediate existing MARS subsystem to accommodate ICD-10 codes - not recommended - system is 20+ years old




November 30, 2009



19.0 OCR H

20.0 OCR M

21.0 OCR H

22.0 PA H

OCR input layout accepts only 5 character diagnosis codes from CMS1500.

OCR input layout accepts all 7 possible characters for CMS1500 diagnosis codes.

Requires front end OCR third party software and OmniCaid interface modifications.

OCR third party software only validates ICD-9 diagnosis code formats.

OCR third party software will need to validate that all diagnosis codes on the claim are in either ICD-9 or ICD-10 diagnosis code formats based on the claim's LDOS.

New logic for both ICD-9 and ICD-10 diagnosis code format validation will need to be developed.

OCR claims preprocessors only validate ICD-9 diagnosis code formats.

OCR claims preprocessors will validate ICD-9 and ICD-10 diagnosis code formats depending the on claim's ICD version indicator.

New logic for ICD-10 diagnosis code format validation will need to be developed.

Prior Authorization allows specification of ICD-9 diagnosis code on the line item.

OmniCaid PA Detail edits will allow only ICD-9 format diagnosis codes to be entered on lines with LDOS before 10/1/2013, and only ICD-10 format diagnosis codes on lines with LDOS after that date.

OmniCaid PA edits will use claim's ICD version code to determine if ICD-10 code on the PA needs to be backward converted to ICD-9 for comparison purposes.




November 30, 2009



23.0 PA H

24.0 Provider H

25.0 Reference H

Batch PA interface only allows for specification of a 5 character ICD-9 diagnosis code for line item service type.

Batch PA interface will allow for specification of a 10 character ICD-10 diagnosis code.

Work with TPA's to test modified batch PA interface.

OmniCaid Provider Detail Review tab allows providers to be put on review for a single diagnosis or range of diagnosis codes.

OmniCaid Provider Detail Review tab will not allow review span which include diagnosis codes to straddle the ICD-10 implementation date. Only ICD-9 diagnosis codes will be allowed before that date, only ICD-10 diagnosis codes on or after that date.


Reference subsystem diagnosis tables assume ICD-9 format.

An ICD version code column will be added to Reference subsystem diagnosis tables to allow system to distinguish between codes in ICD-9 and ICD-10 formats.

Logic to check for either ICD-10 or ICD-9 version may need to be added to every query against these tables to retrieve the desired data. It must be added in all cases where the query is looking for codes that apply to a specific claim DOS.




November 30, 2009



26.0 Reference H

27.0 Reference H

OmniCaid Reference windows assume ICD-9 diagnosis codes.

An ICD version code selection capability will be added to the OmniCaid Reference windows to enable users to select either ICD-9 or ICD-10 codes or both. "Both" format option will be disallowed when the user is adding a new diagnosis code.

ICD version selection option added to search windows that allow diagnosis code entry.

Modified data window queries to return codes based on user's ICD version selection.

OmniCaid application enforces ICD-9 formatting rules for diagnosis codes.

OmniCaid diagnosis code format edits will be enforced based upon the ICD version entered by the user.

New PowerBuilder diagnosis edit function for ICD-10 based on user entered ICD version code.




November 30, 2009



28.0 Reference H

29.0 Reference MI

Existing ICD-9 diagnosis codes are only valid for DOS prior to 10/1/2013.

Need an automated load and conversion process for new ICD-10 diagnosis codes.

ACS will use CMS data files as the basis for loading the new ICD-10 diagnosis codes. Once the codes 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).

Existing ICD-9 diagnosis code update process relies on manual intervention.

Due to the expected increase in the volume of new codes for ICD-10, we highly recommend additional automation of the annual update process.

Meet with stakeholders to determine the feasibility of additional automation of the ICD-10 code annual update process.

Determine new default equivalent codes for setting indicators on the diagnosis code table.




November 30, 2009



30.0 TPL H

31.0 Web Portal H

Retro TPL mass adjustment selection process uses the TPL edit module which posts certain edits based on the diagnosis codes present on the claim to determine whether to create TPL billing records.

Retro TPL mass adjustment selection process will be modified to use either ICD-9 or ICD-10 format diagnosis codes for TPL billing determinations based on the claim's ICD version code.


Web portal EHR inquiry allows input diagnosis codes in ICD-9 format only.

Web portal EHR inquiry will allow input diagnosis codes in ICD-9, ICD-10 or either ICD-9 or ICD-10 format depending on the inquiry DOS range.

Modify web portal EHR inquiry to allow input diagnosis codes in ICD-9 format only if DOS range ends prior to 10/1/2013 or ICD-10 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.




November 30, 2009



32.0 Web Portal M

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

Web portal Claim Status inquiry detail displays assume ICD-9 format diagnosis codes.

Web portal Claim Status Inquiry detail will display both ICD-9 and ICD-10 format diagnosis codes depending on the claim's ICD version.

Modify web portal Claim Status inquiry detail display to accommodate both ICD-9 and ICD-10 codes.

11 - Appendix A.8.1 - ICD-10 Diag Code BRC (11-24-2009)

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