ICD-10 clinical scenarios can be used to understand potential risks and variations in health care claims reimbursement for procedures that are provided after October 1, 2014.

For example, an 82-year old female patient with a cardiovascular condition could have a procedure under ICD-9 CM with a correlating Diagnosis Related Grouping (DRG) of 251[1] and a reimbursement for the procedure of $9,622.80.  Under ICD-10 after October 1, 2013 this same procedure, if documented and coded one way would lead to the same DRG of 251 and therefore would be “revenue neutral” under ICD-10.  However if documented and coded differently this procedure could result in a DRG 230[2] the reimbursement might shift to $24,343, or a reimbursement risk of $14,721.  This is one hundred and fifty three percent (153%) of the original reimbursement.  However, CMS suggests cross-walking this procedure to a DRG 254[3], which could result in a third reimbursement outcome.

Understanding how ICD-10 changes medical concepts can help hospitals and other health care providers plan for shifts in reimbursement, and it can help health plans and large self-insured employers to design a path forward in redesigning medical policy and benefit plans.  Proper ICD-10 impact assessment and ICD-10 implementation planning can help health care companies improve their planning and preparation for the best transition possible.  ICD-10 clinical documentation improvements, coder quality and other aspects can be addressed via the right methodology and reference implementation model.

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  • [1] Percutaneous Transluminal Coronary Angioplasty – MS-DRG 251 “Percutaneous cardiovascular procedure without coronary artery stent without MCC”
  • [2] Coronary Bypass – MS-DRG 230 “Other cardiothoracic procedures without CC/MCC”
  • [3] Source: CMS https://www.cms.gov/acuteinpatientpps/downloads/CMS-1533-FC.pdf – Vascular Repair – MS-LTC-DR 254 Other vascular procedures without CC/MCC

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