FAQS: QUALITY ACHIEVEMENTS AND ICD-10
Is Healthgrades Mortality and Complications Outcomes Methodology Changing?
Healthgrades methodologies will NOT change during the healthcare industry's transition to and
implementation of ICD-10 codes. As our cohorts, ratings, awards and other quality performance
products are transitioned to ICD-10, their statistical validity and clinical meaning will be sustained. The
processes, protocols, expertise and technical tools used in Healthgrades ICD9-10 Transition will
preserve the intended definitions of:
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Inclusions and exclusions for patient cohorts of conditions and procedures for which hospital
performance is evaluated
Complications that patients experience during their stay relative to the conditions and procedures
evaluated
Patient demographic and clinical risk factors that influence patient outcomes in significant and
systematic ways in Healthgrades risk-adjustment process.
What is the ICD9-ICD10 Transition?
The ICD-9 code sets, used to report medical diagnoses and inpatient procedures, will be replaced by
ICD-10 code sets on October 1, 2015. ICD-10 consists of two parts:
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
ICD-10-CM diagnosis coding which is for use in all U.S. health care settings.
ICD-10-PCS inpatient procedure coding which is for use in U.S. hospital settings.
When does the ICD9-ICD10 Transition take place?
On July 31st, 2014, the U.S. Department of Health and Human Services (HHS) issued a rule finalizing Oct.
1, 2015 as the new compliance date for health care providers, health plans, and health care
clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases.
This deadline allows providers, insurance companies and others in the health care industry time to ramp
up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015.
Why is the ICD9-ICD10 Transition occurring?
The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical
conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is
inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes
that can be created, and many ICD-9 categories are full. The World Health Organization’s (WHO)
International Classification of Diseases has served the healthcare community for over a century. The
United States implemented the current version (ICD-9) in 1979. While most industrialized countries
moved to ICD-10 several years ago, the United States is just now transitioning with a final compliance
date of October 1, 2015.
© Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be
reproduced or redistributed without the express permission of Healthgrades Operating Company,
Inc.
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Healthgrades ICD-10 Transition Initiative
Who is affected by the ICD9-ICD10 Transition?
ICD-10 Compliance is mandatory for all HIPAA-covered entities, including those who do not handle
Medicare claims. There are no exceptions to any HIPAA-covered entities. Organizations that are not
governed by HIPAA who use ICD-9 codes should be aware that their coding may become obsolete in the
transition to ICD-10.
ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health
Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare or Medicaid
claims. The change to ICD-10 does not affect CPT coding for outpatient procedures.
Health care providers, payers, clearinghouses, and billing services must be prepared to comply with the
transition to ICD-10, which means: All electronic transactions must use Version 5010 standards, which
have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010
accommodates ICD-10 codes. ICD-10 diagnosis codes must be used for all health care services
provided in the U.S., and ICD-10 procedure codes must be used for all hospital inpatient procedures.
Claims with ICD-9 codes for services provided on or after the compliance deadline cannot be paid.
Why does Healthgrades have to participate in the ICD9-ICD10 Transition?
ICD-9 code sets are used to identify inclusions, exclusions, risk factors and complications for
Healthgrades risk-adjusted models for evaluating hospital quality of care. These elements are the
foundation of our ratings and many other quality products. In many cases the ICD-10 codes can be
mapped directly to ICD-9 codes we currently use to fill the various roles in our models. There are several
cases where applied mapping and clinical and statistical review are required, for example:
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ICD-10 has lower resolution (multiple ICD-9 codes map to only one ICD-10)
New ICD-10 codes have been created with no ICD-9 equivalent
The ICD-10 code has multiple criteria, which map back to other ICD-9 codes and creates new
relationships between the ICD-9 codes which have not previously been encountered.
What is Healthgrades doing to prepare for ICD9 to ICD10 Transition?
Since 2010, Healthgrades has been preparing for the healthcare industry’s transition from ICD-9 to ICD10 codes. During this timeframe, we have successfully built the technical tools and infrastructure for
mapping between ICD-9 and ICD-10, receiving data with ICD10 codes on October 1, 2015 and
transitioning our ICD9-based Quality Deliverables and Products. Healthgrades’ goal is to maintain the
integrity of all of our models from both a statistical and clinical perspective. Specifically, the
modifications to our hospital claims data processing system will maintain: a) patient cohorts of
conditions and procedures for which hospital performance is evaluated; b) definitions of complications,
and c) the definitions of risk factors in our risk-adjustment process.
As of January 1st, 2015 Healthgrades has begun a 5.5 year strategic plan to translate all quality products
into the ICD-10 language. This plan contains four phases that correspond with various receipt dates of
data coded in the ICD-10 language.
Phase 1: Applied Mapping and Clinical Review (2015)
During this phase work will focus on creating the clinical models in the combined ICD-9/ICD-10 coding
so that data coded in both formats can be processed for parallel use.
Phase 2: Applied Mapping Refinement and Initial Impact Analysis (2016)
During this phase extensive evaluation of the clinical appropriateness and coding effectiveness of our
combined mapping models will be evaluated. Efforts will be focused on evaluating code usage in client
facing clinical products.
© Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be
reproduced or redistributed without the express permission of Healthgrades Operating Company,
Inc.
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Healthgrades ICD-10 Transition Initiative
Phase 3: ICD-10 Model development and testing (2017 – 2018)
During this phase MedPAR data will begin to arrive in the ICD-10 format. In depth analyses will be done to
evaluate the statistical consistency of the ICD-9/ICD-10 combined coding and the relationship ICD-10
coding practices have on the statistical models.
Phase 4: Final Evaluation and Refinement of ICD-10 models (2019 – 2020)
During the first half of this phase MedPAR based models will transition into ICD-10 only. At the end of
this phase All-Payer based models will also transition into ICD-10 only models. At this time all
Healthgrades related quality products will be fully translated to the ICD-10 format.
What is Healthgrades timeline for a full conversion of quality ratings and awards to
ICD-10?
The conversion process will take approximately 5 years. Healthgrades utilizes 3 years of data for all
quality ratings and awards. Healthgrades receives these data sources with as much as a 2 year delay. The
graphs below display the time frame in which Healthgrades will receive ICD-10 data from the Medicare
and All payer state data sources.
% of
ICD
code
100%
50%
2016
2017
2018
2019
2020
2021
0%
All
payer
ICD10
All
payer
ICD-9
Award Year
% of
ICD
code
100%
MedPAR
ICD-10
50%
2016
2017
2018
2019
2020
2021
0%
MedPAR
ICD-9
Award Year
© Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be
reproduced or redistributed without the express permission of Healthgrades Operating Company,
Inc.
3
Healthgrades ICD-10 Transition Initiative
Who should I contact at Healthgrades for more information on the ICD9 to ICD10
Transition?
If you have questions or need additional information on Healthgrades transition from ICD-9 to ICD-10
codes, please contact:
[email protected]
© Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be
reproduced or redistributed without the express permission of Healthgrades Operating Company,
Inc.
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