New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code

# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS There is no ICD ACS will add an ICD version code column H Anywhere there is a need version code on to the Claims Header table so that to distinguish between the Claims OmniCaid downstream logic can easily tell ICD-9 and ICD-10 Header Table. which ICD code format applies to the diagnosis or ICD diagnosis and ICD surgical/inpatient surgical/inpatient procedure codes on that claim. The ICD procedure code formats, version indicator will be set to ICD-9 for OmniCaid logic will be claims with LDOS (or discharge date, modified to look at the when present, for inpatient claims) prior to claim ICD version code in 10/1/2013, and otherwise, to ICD-10. order to decide the ICD format that should apply CMS has stated that ICD-9 claims with to the logic. 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. New Business Rule Notes

1.0

All

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 1 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Impact on MMIS There is no With ICD-10, there will be a need in a H New ICD code crosswalk current need to number of areas (Claims UR, special logic tables and new crosswalk based on hard-coded diagnosis code crosswalking logic will different ranges, etc.) for the capability to need to be added at versions of ICD crosswalk ICD-10 codes back to a various points throughout diagnosis codes. corresponding ICD-9 code(s), or to the system. crosswalk ICD-9 codes forward to the corresponding ICD-10 code(s). New Business Rule Assumptions Notes

2.0

All

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, and 2) Would necessitate manual processing of some claims, or would require automated assumption of which scenario to use.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 2 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS OmniCaid OmniCaid claims entry/correction will use H Modify OmniCaid claims claims header LDOS (or discharge date when adjudication engine to entry/correction applicable) to determine whether the base diagnosis edits on assumes ICD-9 claim ICD version code should be set to claim R_ICD_VER_CD diagnosis codes. ICD-9 or ICD-10 and whether diagnosis throughout. codes entered should be in ICD-9 or ICD10 format. Review diagnosis edit descriptions and resolution instructions for explicit references to ICD9 and change them to ICD. OmniCaid COS determination logic uses ICD9 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. H 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. New Business Rule Notes

3.0

Claims

4.0

Claims

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 3 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Impact on MMIS DRG pricing CMS has indicated that it expects the ICDH Logic will be added to logic uses use 10 DRG grouper to be ready by the DRG pricing so that ICD-9 format implementation date. DRG pricing for ICDclaims will use the diagnosis codes 9 claims will continue to use ICD-9 format version of the DRG as input for input for grouper. DRG pricing for ICD-10 grouper appropriate for grouper. claims will use ICD-10 format input for their ICD format. grouper. Claims UR medical criteria can include/exclude a range or a list of ranges of ICD9 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. H ICD-10 to ICD-9 reimbursement crosswalk logic will need to be factored into diagnosis related edits that involve historical claim data. New Business Rule Assumptions Notes

5.0

Claims

6.0

Claims

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 4 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS Claims UR There are currently only 3 diagnosis code H ICD-10 to ICD-9 medical limit ranges and no lists associated with UR reimbursement crosswalk parameters can Medical limit parameters. ACS will logic will need to be include/exclude convert existing UR limit parameter factored into diagnosis a range or a list diagnosis codes to ICD-10 format. related edits that involve of ranges of ICD- Whenever an in process or history claim historical claim data. 9 diagnosis is an ICD-9 claim, UR edit logic will use codes. the CMS Reimbursement mapping crosswalk to backward convert any ICD10 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. New Business Rule Notes

7.0

Claims

8.0

Claims

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.

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

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 5 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS OmniCaid cost OmniCaid cost center assignment logic H Diagnosis code hold center will use either ICD-9 or ICD-10 diagnosis areas in the cost center assignment logic codes to determine how to populate the assignment module need uses ICD-9 Family Planning cost center based on the to be expanded to 10 diagnosis codes claim's ICD version code. characters to match the to determine length used elsewhere in how to populate the system. This will the Family accommodate ICD-10 Planning cost codes. center. May need input from MAD during forward conversion for cases where the ICD-9 code has multiple choices for ICD-10 equivalent codes. New Business Rule Notes

9.0

Claims

10.0 Claims

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.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 6 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS Claims client OmniCaid will use claim ICD version code M All existing list entries EOMB claim and list effective dates to pick the correct with ICD-9 diagnosis selection list entries for excluding claims from codes will be ended as of excludes claims EOMB selection. 9/30/2010. ICD-9 to ICDwith certain 10 crosswalk will need to diagnosis codes be used to create new list using a system entries with equivalent list. ICD-10 diagnosis codes and effective date 10/1/2013. 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. M May need input from MAD during forward conversion for cases where the ICD-9 code has multiple choices for ICD-10 equivalent codes. New Business Rule Notes

10.1 Claims

11.0 Data Warehouse

12.0 EMC

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

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

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 7 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS EPSDT Detail EPSDT Detail update process will use the M Will need to crosswalk update process ICD version code on the claim to the existing ICD-9 uses various determine when it should use ICD-10 or diagnosis codes to their diagnosis codes ICD-9 diagnosis codes for comparisons ICD-10 equivalent(s) and for comparisons and setting of various indicators that add logic to use the ICD and setting of determine whether and how claim should version code on the claim various be reflected in the EPSDT database. to determine which indicators that format to compare. determine whether and how claim should be reflected in the EPSDT database. New Business Rule Notes

13.0 EPSDT

14.0 EPSDT

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.

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.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 8 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Accounting Claim transaction COS determination logic uses ICD9 diagnosis codes to determine whether COS on the transaction file should be set to EPSDT. OmniCaid system lists of diagnosis codes used in various edits assume ICD-9 format. New Business Rule Level of Impact Description Assumptions Impact on MMIS M 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. Notes

15.0 Financial

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.

16.0 General

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.

All existing list entries with ICD-9 diagnosis codes will be ended as of 9/30/2010. ICD-9 to ICD10 crosswalk will need to be used to create new list entries with equivalent ICD-10 diagnosis codes and effective date 10/1/2013. Conversion - Existing diagnosis list entries, if any, will be ended 9/30/2013. New entries will be created with ICD10 equivalent codes effective 10/1/2013.

17.0 Managed Care

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.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 9 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Diagnosis code length is 5 characters long throughout MARS subsystem. New Business Rule Level of Impact Description Impact on MMIS MI Possible Impact: Assumptions Notes

18.0 MARS

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 ICD10 codes using the CMS Reimbursement Mapping Crosswalk as part of monthly MARS processing 2) Replace MARS with a third party EMARS solution before October 2013 3) Change length of fields throughout MARS subsystem

19.0 OCR

OCR input OCR input layout accepts all 7 possible layout accepts characters for CMS1500 diagnosis codes. only 5 character diagnosis codes from CMS1500.

1) M - Backward conversion for MARS already exists. Enhance it to backward convert ICD10 codes to ICD-9. 2) H - Build multiple MMIS data interfaces for third party solution 3) H - Remediate existing MARS subsystem to accommodate ICD-10 codes - not recommended system is 20+ years old Requires front end OCR third party software and OmniCaid interface modifications.
New logic for both ICD-9 and ICD-10 diagnosis code format validation will need to be developed.

20.0 OCR

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.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 10 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS OCR claims OCR claims preprocessors will validate H New logic for ICD-10 preprocessors ICD-9 and ICD-10 diagnosis code formats diagnosis code format only validate ICD- depending the on claim's ICD version validation will need to be 9 diagnosis code indicator. developed. formats. 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. H OmniCaid PA edits will use claim's ICD version code to determine if ICD10 code on the PA needs to be backward converted to ICD-9 for comparison purposes. Work with TPA's to test modified batch PA interface. New Business Rule Notes

21.0 OCR

22.0 PA

23.0 PA

Batch PA Batch PA interface will allow for interface only specification of a 10 character ICD-10 allows for diagnosis code. specification of a 5 character ICD9 diagnosis code for line item service type.

24.0 Provider

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.

All existing list entries with ICD-9 diagnosis codes will be ended as of 9/30/2010. ICD-9 to ICD10 crosswalk will need to be used to create new list entries with equivalent ICD-10 diagnosis codes and effective date 10/1/2013.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 11 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS Reference An ICD version code column will be added H Logic to check for either subsystem to Reference subsystem diagnosis tables ICD-10 or ICD-9 version diagnosis tables to allow system to distinguish between may need to be added to assume ICD-9 codes in ICD-9 and ICD-10 formats. every query against format. 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. 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. H 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. H New PowerBuilder diagnosis edit function for ICD-10 based on user entered ICD version code. New Business Rule Notes

25.0 Reference

26.0 Reference

27.0 Reference

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.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 12 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS Existing ICD-9 Need an automated load and conversion H ACS will use CMS data diagnosis codes process for new ICD-10 diagnosis codes. files as the basis for are only valid for loading the new ICD-10 DOS prior to diagnosis codes. Once 10/1/2013. 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 ICD9 diagnosis indicators as the basis for the initial setting of the indicators on the corresponding ICD-10 code(s). New Business Rule Notes

28.0 Reference

29.0 Reference

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.

MI

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.

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 13 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS Retro TPL mass Retro TPL mass adjustment selection H Will need to crosswalk adjustment process will be modified to use either ICDthe existing ICD-9 selection 9 or ICD-10 format diagnosis codes for diagnosis codes to their process uses TPL billing determinations based on the ICD-10 equivalent(s) and the TPL edit claim's ICD version code. add logic to use the ICD module which version code on the claim posts certain to determine which edits based on format to compare. the diagnosis codes present on the claim to determine whether to create TPL billing records. 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. H 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. New Business Rule Notes

30.0 TPL

31.0 Web Portal

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 14 of 15

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New Mexico MMIS HIPAA 2 Assessment Business Rules Comparison ICD-10 - Diagnosis Code
# Subsystem Current Business Rule Level of Impact Description Assumptions Impact on MMIS Web portal Web portal Claim Status Inquiry detail will M Modify web portal Claim Claim Status display both ICD-9 and ICD-10 format Status inquiry detail inquiry detail diagnosis codes depending on the claim's display to accommodate displays assume ICD version. both ICD-9 and ICD-10 ICD-9 format codes. diagnosis codes. New Business Rule Notes

32.0 Web Portal

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

Worksheet: ICD-10 Diagnosis Code

Appendix A.8.1 - ICD-10 Diagnosis Code Page: 15 of 15

November 30, 2009