HCSC started the process in the third quarter of , and products are currently available with attributes that were not available at the time the decision was made. The business rules were translated using approximate matches, exact matches, combination codes, and scenarios.
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A decision was required for each business rule to look for the set of translations that would best adhere to the intent of the business rule being translated. The same held true for combinations and scenarios. Next, the business impact, benefit impact, and financial impact that the decision would have on overall operations had to be determined.
An assessment was made of how many processes based on that decision would require manual intervention on a day-to-day basis. How much would that manual process cost in dollars and personnel? All of these decisions related to business rules had to be factored into the final approach our corporation would take regarding GEMs.
Only your organization and subject-matter experts can decide which approach is best for your situation.
This approach is called dual processing. Providers could continue to submit ICDCM claims for services with dates prior to October 1, , for up to one year after the date of service. Once the decision was made to perform dual processing, the remainder of the project structure, impact assessment, requirements, design and development, testing, and piloting plans and concepts followed logically. Of course, far more detailed analyses were performed during a more critical, in-depth look at all of these decisions. It is vital to have someone on the project team who completely understands the GEMs and clinical coding.
When the GEMs were initially loaded into the tool we developed, it was found that translating accurately between the two code sets required the use of both the forward and backward GEMs. To actually translate from one code set to the other, our coders also had to access the coding books and retrieve the codes missing from the first pass at translation, using the GEMs, in order to achieve the most accurate translational result. Because many coders are not clinically trained and are not up to date on the latest clinical diseases or interventions, a secondary level of review had to be instituted.
Clinicians are valuable assets in the translation process because they presumably already have this expertise. The process requires someone with training in coding, anatomy, and medical terminology as well as experience in coding production work. The qualifications are specific, exacting, and without shortcuts.
Coders have told the project team that the changes in terminology for the root operations are the most difficult part of the transition for experienced ICDCM coders. The GEMs are the foundational data set. Coders can use the tool to validate that the translation of each business rule correctly meets the intent of the business rule. Achieving an accurate translation may require adding and deleting codes from the code set returned from the GEMs. High technology is not required if there is only a small volume of data to translate.
However, if large amounts of data require translation e. To use the GEMs effectively, it must be understood how they actually work. Regardless of whether they are downloaded from the CMS Web site or supplied by a vendor, the GEMs offer four types of possible translational choices. When the GEMs are first downloaded into an Access database, they are formatted with the following structure: Appearing first is the source code set or the code set to translate from, with a description of the code.
Second, across the code line, is the target code set or the code set to translate to. Then there are five columns that have a value of either one or zero. HCSC used the GEMs to designate approximate matches, no matches, exact matches, combinations, scenarios, and choices, in that order.
The definitions of those designations are as follows:. The types of results from the GEMs were categorized according to the forward and backward mappings. The figures below are the approximate figures used when the process was begun. We were able to further determine what chapters caused the greatest risk based on numbers of combination codes, scenarios, or codes that had no matches.
This allowed the team to target an approach based on claim volume, dollars reimbursed, and risk.
This information did result in a slight revision of the approach. Fortunately, the number of missing codes decreased to approximately 13, when the chapter on external causes of injury was eliminated from the mapping. All of these numbers may have changed since that initial review took place in the fall of It is important to note how many codes translated to approximate matches and then look at those approximate matches to determine if they capture the desired concept in the translation of business rules or processes.
Also, combination codes and scenarios, especially in the procedure code sets, may require a change to the way codes are stored, retrieved, and tracked. Translating business rules may require looking at all of the codes in the combination and scenario sets to determine if the intent of the business rule has been met.
Finally, for the codes that have no match in the target code set, you must include them in your decision process and determine how you will accommodate them. The results of this analysis emphasize that codes must be forward mapped and backward mapped to achieve the best outcome. For example, it must be decided which additional codes must be included or deleted to serve the intent of established business rules. Finally, the analysis helps to make decisions about how to approach the translation process initially and what complications need to be anticipated.
First, the GEMs were used as a training tool. The coders were given time to study, and as a result, they all passed the exam.
This allowed them to practice while our internal software staff was designing and developing a tool for them to use for the business-rule translation process. The coders worked on the diagnosis codes and procedure codes in the GEMs on a chapter-by-chapter basis. As the validation process continued, HCSC concurrently reviewed and reevaluated all software tools and business processes to find every instance in which an ICDCM code impacted a business rule.
The major challenge for those choosing this process will be to discover every place an ICDCM diagnosis or procedure code resides.
Some of the business rules used in your software will be highly visible and easy to find and access. Other business rules may be far more challenging to locate, but it is critical to how business is conducted in your organization to find all uses of these codes in your business rules. It is strongly recommended to institute a process for continuously updating your rules and tracking any changes you have made to your rules as well as the rationale for any changes. Some of the business rules in software tools or systems are hard coded, while other processes or business rules require us to query external databases for single codes or code ranges.
Regardless of how and where you use codes in business rules, you must determine how to translate and update them. An example of the translation of a code range is A coder with clinical knowledge must look at all of the codes in that range to ascertain if the codes meet the stated intent of the business rule in question, and IT experts must determine how and where those decisions are stored and accessed.
Once these instances of ICDCM codes are found, then the purpose or intent of the rule, or the actions they execute, are used to define the business rule. Understanding the purpose of each business rule is critical. In addition, any codes that might not have been included in the directional mapping tool were taken as alternative translations. For example, the utilization management department of the organization may have a business rule that states: To achieve the goal of the business rule, it is vital to translate only to the codes that result in the same clinical and business outcome.
This information may be important to track provider follow-up on the initial myocardial infarction and to differentiate it from subsequent events in the same anatomical distribution. To get to the same information, it is essential to use code I Performing a straight query of the GEMs, however, does not return those values. The coder must add that value from the ICDCM code set while also understanding what the intent of the rule is and what information is necessary to get to the best translation of the business rule.
Utilizing the steps detailed above, the coders translated business rules.
To achieve that goal, it required seven coders working for 21 weeks at 30 hours per week, for a total of 4, coder hours. Every impacted entity, whether a payer, institutional provider, professional provider, vendor, or clearinghouse, is on a tight schedule to review how business is currently being done. All instances in which ICDCM codes are used in the current state of the business must be retrieved and isolated. It is critical to understand the intent of each business rule or process that leverages the ICDCM diagnosis or procedure codes.
Some of the key steps to reach that new state are listed below. The business of healthcare is about the delivery, and the payment for the delivery of, healthcare services or supplies to achieve the best quality outcomes for our respective populations. To achieve this goal, the healthcare industry must be effective and efficient in the use of the healthcare dollar. Medical coding is the language used to transmit healthcare documentation, and the healthcare industry is about to switch languages for the first time in more than 30 years.
There is no automated crosswalk. Adopting the new code set will not be a simple IT fix. It will require a great investment of time, money, and human resources in the preparation, design, conceptualization, simulation and modeling, testing, piloting, and finally adoption of the new system. National Center for Biotechnology Information , U. Perspect Health Inf Manag. This article has been cited by other articles in PMC. Multiple Options to Consider for Optimal Benefit How does an organization best decide which of the many available approaches to take?
Financial Considerations—Direct and Indirect Decisions are much easier to make in a vacuum, apart from financial concerns. Identifying Hidden Costs Additional questions must be considered. Four GEM Options The multiple options already discussed can be merged into four separate approaches to consider, each of which has a different method for using the GEM tool.
May change the intent of the originally submitted claim. May make a single mapping decision or limit possible mapping decisions. No live mapping required. May change the intent of the originally submitted claim when it is used in reporting and other internal processes. Data mismatches may occur with this approach. Requires a great deal of initial business rule mining, discovering, and documenting the intent of all identified business rules, and clinical translational work.
GEMs can be used as a starting point.
Results in total recoding of all affected systems and processes. Requires the most money, time, and personnel. International development with strong emphasis in developing organizations, standards, commercial, claims and contractual policies and procedures aligned to the overall programs objectives and implementing the same to achieve successful completion of projects and programs with capability of quickly adapting to changing environment and finding new ways and solution to achieve desired results. Researcher and Author of many books currently 87 including: Are you an author?
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