ICD10 and Medi-Cal Processing – Preparing for Chaos

As the ICD10 deadline approaches, providers and health plans (and their vendors) prepare for the transition with varying levels of effort, efficiency and success.  Although it is true that the organizations that plan, train and test for this event will be more prepared for the transition from ICD9 to ICD10 than their competitors, no organization will avoid the consequences of an industry that seems to struggle with change.

What will happen when Medicare requires the ICD10 codes and other health plans are unable to accept them?  From the provider perspective, the bottom line is receiving reimbursement for your services.  Regardless of the “rules”, providers have always had to comply with reality to get their money.

prepare for chaos
ICD10 Chaos on the horizon.

Although there has not been any change as fundamental or substantial as ICD10 recently, other changes to industry standards did not go smoothly.  The transition from the ANSI 4010 version of the 837 claim file to the 5010 version took over one year until all health plans we worked with accepted the 5010 specification.  The last one we converted over was Medi-Cal, the California Medicaid program.  This is hardly an insignificant payer.  Out of curiosity, I visited their site to discover how they were going to handle the transition given the fact that they have to legally comply with the 10/1/15 deadline, like all other health plans.  Here is a link to their FAQ page:

Medi-Cal FAQ Page.

If you go down to question #8, “How is Medi-Cal addressing the implementation of ICD-10?”, you will find this response:

“Medi-Cal will be using a crosswalk solution in the legacy California Medicaid Management Information System (CA-MMIS). Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy. Claims will be run against the crosswalk to determine the ICD-9 value to process through the system. The crosswalk will only be used temporarily for ICD-10 claim adjudication while the implementation of our new MMIS system is being completed. Once the new system is online, Medi-Cal will adjudicate all claims natively using ICD-10 and the crosswalk will no longer be used.”

As most providers have learned, ICD10 is a much larger and more detailed code set compared to ICD9.  For this reason, there is no reliable system for mapping a crosswalk of values in either direction.  Furthermore, it appears that Medi-Cal has mapped these values themselves and kept the results a secret.

According to item #10, this crosswalk will not be published.  This will make it impossible for the provider to know what diagnosis code was actually assigned to their claims.  Although they state that this process is temporary, based on our experience with the 4010 to 5010 transition, I would not expect a transition to processing claims using “native” ICD10 in the near future.

Although I have decided to pick on Medi-Cal, this is not a unique example.  Other health plans, unprepared for the transition, will also come up with creative ways to comply with the 10/1/15 deadline without actually updating their systems.  Each of these solutions will have similar issues with accuracy and transparency.


By Kalon Mitchell, President – MEDTranDirect