Impact of ICD-10-CMS/PCS on MS-DRGs
Introduction
Procedural and diagnosis codes, as well as their associated descriptions, play an important role in numerous health care processes. For instance, both hospitals and the Centers for Medicare and Medicaid Services (CMS) rely on coded information to help run primary care activities. Such activities include reimbursement management, care optimization, and population health monitoring among others. As this happens, there is a need for constant technological changes and upgrades to facilitate accuracy and completeness in data transmission. The recent movement from the ICD-9 code set to ICD-10 is a perfect example of such upgrades. This paper shows that the transformation will have a positive impact on Medicare payments.
MS-DRGs is an acronym for Medicare Severity Diagnosis Related Groups. The system has become commonplace among healthcare providers due to the ever rising number of patients under Medicare. The MS-DRG payment system has a provisionary range from 001-999 with numerous unused numbers for future expansion. The American Health Information Management Association (2012) states that MS-DRGs enable the CMS to offer improved hospital reimbursement for facilities that serve additional patients under critical care. It follows that there exists reduced reimbursement for facilities that admit a smaller number of severely ill patients (AHIMA, 2012).
The payment system assigns one MS-DRG to each inpatient stay at a facility. According to Fox and Keiffer (2008), the CMS directs that accredited professionals assign these systems using primary and additional diagnoses, primary and additional procedures, gender, and discharge statuses. These individuals, usually HIMs, rely on a complete coding system that follows a preplanned protocol to facilitate subsequent reimbursements. Hospitals would receive a predetermined fee for the treatment of patients in a given MS-DRG. This reimbursement overlooks the actual expenditure of the said treatment procedure. Instead, the MS-DRG exclusively concentrates on setting reimbursements that target Medicare patients (Fox & Keiffer, 2008).
The ICD-10 Development Process
The CMS and 3M Health Information System (HIS) involved the National Center for Health Statistics in the development of the ICD-10. The NCHIS collaborated with related organizations to incorporate every possible clinical detail in morbidity classification as well as appropriate code provision for the ultimate information delivery. The two contractual departments designed the ICD-10 version to reflect present and current technological situations. The current objective of the ICD-10 is to improve the efficiency and accuracy of procedural coding. It offers superior specificity, improved communication, and reduced training efforts. The entire platform incorporates four primary traits, namely expandability, completeness, multi-axial structures, and standardized terminologies (AHIMA, 2012).
The primary element in the development of the ICD-10 process is the General Equivalence Mappings (GEMs). GEMs are a form of public domain mapping system created to offer all users of coded data in health care a tool for converting systems, analyzing data, and developing application-specific mapping. They allow for the identification of the corresponding codes between ICD-09 as compared to the ICD-10 version. GEMs are bidirectional as they include both forward and backward mappings. The CMS developed GEMs to facilitate consistency in aggregate data and serve as a tool used to convert between ICD-9 and ICD-10 codes. In the making of ICD-10 codes, CMS designed GEMs in ways that supported all major uses of coded healthcare information (AHIMA, 2012).
ICD-9 v ICD-10
It is not possible for MS-DRGs, in their present forms, to be developed with the ICD-10 coding version. AHIMA (2012) notes that the need for the development of the ICD-10 came from the inadequacy of the ICD-9 classification and terminologies concerning current medical practices. Also, the system lacks the space to accommodate new codes that help in addressing newly documented conditions, technologies, and EBP (AHIMA, 2012).
Conclusion
In conclusion, the change in ICD codes to the superior ICD-10 version will have a positive yet minimal impact on Medicare payments for hospitals and the CMS. Ideally, the objective of the ICD-10 is to build on the weaknesses of its outdated counterpart by expanding the purpose, scope, and content of the coding system. It captures additional critical information such as clinical detail, risk factors, emergent diseases, ambulatory services, as well as develops group diagnosis. This capability shows the provision of superior disease categories and other health related conditions compared to the ICD-9 system. The adequacy of implementation and collection of morbidity, as well as mortality data, shows a minimal improvement in Medicare reimbursements.
References
AHIMA. (2012). The ICD-10-CM/PCS Implementation Toolkit . Retrieved from American Health Information Management Association: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049431.hcsp?dDocName=bok1_049431#icd-10-cm-pcs
Fox, W., & Keiffer, K. (2008). Dont Underestimate the Power of MS-DRGs on your Bottom Line. Seattle: Milliman Inc.
Mills, R., Butler, R., Averill, R., McCullough, E., Fuller, R., & Bao, M. (2015). The Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments. Retrieved from American Health Information Management Association: http://journal.ahima.org
