Know where your EHR vendor gets ICD-10 CM codes

The countdown widget on CMS.gov tells the story: less than 63 days before ICD-10 CM goes into effect. We are still way behind. Many vendors still have not released their ICD-10 CM code functionality or they are only operating in test environments.

Two stubborn myths persist for providers:

1.) ICD-10 CM doesn’t apply to us (It does!);

2.) Our EHR vendor has ICD-10 CM taken care of for us (Don't be so sure!).

Have you questioned the source of the vendor’s ICD-10 codes? Do you even know where they come from or where they will be positioned in the EHR? And more importantly, will your vendor tell you? But don’t expect a concrete, straight-forward answer. 

Transparency has been hard to come by regarding EHR vendor sources. That said, we do know some critical items that will have significant impact on the diagnoses your clients will ultimately be assigned in their digital medical record. And that should be of keen interest to you.

Where do the codes come from?

Vendors, including medical vendors such as Epic, get their ICD-10 CM codes from a variety of sources. Some sources or processes are:

• Private companies who employ certified coders to “crosswalk” the codes;
• Private companies who have entire divisions devoted to coding;
• Computer programmers who load the codes into the system;
• Centers for Medicare and Medicaid GEMS mappings; or
• The digital version of the codes from the American Psychological Association (APA).

Pretend you have a Paranoid Schizophrenic client. If you use DSM-5’s recommended mapped code to ICD-10 CM for Schizophrenia (F20.9), you will be assigning a ICD-10 CM code of “Schizophrenia, Unspecified.” That’s a problem.

The implications in this case are:

• The use of unspecified codes puts you the provider at risk for not assigning the most specific code available to them per the ICD-10 CM Coding and Documentation Guidelines;
• You are unable to assign the correct diagnosis, Paranoid Schizophrenia (F20.0) if your vendor used the APA digital version only;
• Public health statistics, analytics are impacted; and
• Clinical decision supports or alerts, including those for lab work or medications, will not be able to be leveraged.

Those are only a few implications; trust me, there are more. Schizophrenia is only one example of this problem.

Clinicians do not think twice about where the ICD-10 CM codes come from in their EHRs. More worrisome is the fact that some providers submit a DSM-5 diagnosis to the payer/county/billing office. That entity then “converts” the DSM-5 diagnosis into an ICD-10 CM code. It makes you wonder whose “crosswalk” they are using.  When there isn’t a one-to-one match—and that is quite possible—what happens? There are perfectly legitimate diagnoses that are in the ICD-10 CM that are not contained in the DSM-5. Who is really responsible for diagnosing the client and what diagnosis is now on their digital record?

What to do?

Know the source of your EHR vendor codes, how to validate them, build your own code tables, and fix the problems before you learn the hard way what is really happening behind the scenes. For this reason, Magellen’s embrace of ICD-10 CM codes in Virginia, is right on the mark: Even the well-intentioned industry gold standard can put you at risk in this new world of ICD-10 CM, which is just days away.