icd-10 update understanding and analyzing gems...

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"ICD-10 Update Understanding and Analyzing GEMs"

March 10, 2013

Wednesday, March 20, 2013

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Leola Burke MHSA, CCSAHIMA-approved ICD-10-CM/PCS Trainer

Independent Coding Consultant & ICD-10-CM/PCS Expert, Raleigh, NC & Jacksonville, FL

Ms. Burke has 20+ years of experience in Health Information Management specific to medical record documentation, MS-DRGs, Outpatient APCs, DRG case mix and analysis (CMI), Physician CPT, Evaluation and Management (E/M) and revenue cycle compliance. She has worked with academic medical centers, community hospitals, long term acute (LTAC) hospitals, physician practices and ambulatory surgery centers (ACS). Providing services including clinical documentation improvement and compliance. Experience with ICD-10 CM/PCS development and implementation support. ICD-10 HIM departmental education and training for both providers and payers.


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Learning Objectives

1. What are GEMs and how are they used?

2. Understand how GEMS impact ICD-10

3. Leap I-10 & HL7 tools and uses for ICD-10 conversion.Payer and Provider perspective

4. Code Mapping Tools vs. “Crosswalks” from GEMsA. Reference Maps and Purpose Built MapsB. Why maps for Payers and Providers?C. How the data is used.

5. GEMs Limitations

6. Review current payment structure and correlation to GEMs.A. Financial ImplicationsB. Revenue CostC. GEMs translations impact DRG shifts from ICD-9 to ICD-10.

7. Obtain helpful hints on what you should be doing in your institution.A. Data map project planning and executionB. Conversion Best PracticesWednesday, March 20, 2013

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What are GEMS and how they are used?

The General Equivalence Mappings (GEMs) are a tool that can be used to convert data from ICD-9-CM to ICD-10-CM/PCS and vice versa. Mapping from ICD-10-CM/PCS codes back to ICD-9-CM codes is referred to as backward mapping. Mapping from ICD-9-CM codes to ICD-10-CM/PCS codes is referred to as forward mapping. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for:

•Converting any ICD-9-CM-based application to ICD-10-CM/PCS

•Tracking quality measures

•Recording morbidity/mortality

•Calculating reimbursement

•Link data trends in long-term clinical / research studies


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The GEMs can be used by anyone who wants to convert coded data, including:

All payers

All providers

Medical researchers

Informatics professionals

Coding professionals—to convert large data sets

Software vendors—to use within their own products

Organizations—to make mappings that suit their internal purposes or that are based on their own historical data

Others who use coded data


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The ICD-10 Conversion ToolsLeap I-10 & HL7 Impact on Provider Departments

Revenue Cycle

IT

Data Warehouse

Quality and Clinical

Finance


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Code Mapping Tools vs. “Crosswalks”

Reference Maps Purpose-built Maps

The General Equivalence Mappings (GEMs) is the public domain REFERENCE MAP product developed by a coordinated effort between the Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control & Prevention (CDC), the National Center for Health Statistics (NCHS), any encoder vendor, and other organizations.

Purpose Built Maps (PBM) Refining of foundational reference mapping to conform to the needs of a specific client use based on attributes such as laterality, exclusion notes and chapter changes in ICD-10 to meet the business needs.Purpose built maps-used to identify the closest matching code from all possible codes (e.g., the one best alternative)

GEMs REFERENCE MAPS are a starting point to develop PURPOSE-BUILT MAPS


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“ Crosswalks”

The word “crosswalk” is often used to refer to mappings between annual code updates of I-9. Crosswalking between ICD-10 and ICD-9 should be done primarily to assist with transitioning to ICD-10 and analyze data that spans the conversion time period. They are reference mappings, to help the user navigate the complexity of translating meaning from one code set to the other. They are tools to help the user understand, analyze, and make distinctions that manage the complexity, and to derive their own applied mappings if that is the goal. The GEMs are more complex than a simple one-to-one crosswalk, but ultimately more useful. They reflect the relative complexity of the code sets clearly so that it can be managed effectively, rather than masking it in an oversimplified way.

Please be advised: GEMs are not crosswalks


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• REIMBURSEMENT MAPS

• OUTPATIENT-FOCUSED MAPS

• PUBLIC HEALTH-FOCUSED MAPS

• RESEARCH-FOCUSED MAPS

• OTHER MAPS

PURPOSE-BUILT MAPS


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ICD-9-CM Forwards ICD-10-CM/PCS

ICD-10-CM/PCSBackwards ICD-9-CM

Target system

Source systemForward maping-ICD-9 to ICD-10 GEMs

Backward mapping ICD-10 to ICD-9 GEMs

Target system-code set being map “to”

Source system- code set being map “from”

Reverse look up-using a GEM to look at a target system code to see all the codes in the source that translate to it

REFERENCE MAPS

No maps(orphans) : Attribute in GEMs that when turned on indicates that a code in the source system is not linked to any code in the target system. Explains that there is no map from a source code to a target code

(e.g. ICD-10-CM category Z67-Blood type has no ICD-9-CM equivalent)


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GEMs Conversion SampleICD-9-CM ICD-10-CM

820.8 S72.009A

Fracture ofunspecified part of neck of femur,closed

Fracture of unspecified part ofneck of unspecified femur, initial encounter for closed fracture

820.8 Fracture ofunspecified part of neck of femur,closed

S72.001A Fracture of unspecifiedpart of neck of right femur, initial encounter for closed fracture

OrS72.002A Fracture of unspecified part of neck of left femur, initial encounter for closed fractureOrS72.009A Fracture of unspecified part of neck of unspecifiedfemur, initial encounter for closed fracture

Forwards

Backwards


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Mapping Categories ICD-10 to ICD-9 ICD-9 to ICD-10

No Match 1.2% 3.0 %

1-to-1 Exact Match 5.0 % 24..2 %

1-to-1 Approx Match with 1 choice

82.6 % 49.1 %

1-to-1 Approx Match with Multiple Choices

4.3 % 18.7 %

1-to-Many Match with 1Scenario

6.6 % 2.1 %

1-to-Many Match with Multiple Scenario

0.2 % 2.9 %

Table 1 – Percentages of Types of Matches


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How the data is used

EXTRACT

ANALYZE

REFINE

Step 1: EXTRACT Select all rows containing the code in the source system.

Step 2: ANALYZE Note any flags applied to the code and understand what they convey about the entry.

Step 3: REFINE Select the row(s) of an entry that meet the requirements of the applied mapping.


What is the purpose of the applied mapping?Does the applied mapping require that the code in the source system be mapped to only one “best” alternative in the target system?Will the correct applied mapping vary depending on the documentation in the record?

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Additional Information Specified in Flags

• Read as 1=On, 0=Off

• Three different flags

– Approximate

– No Map

– Combination


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Combination Flag 1 “On”= Combination

Combination: This is an entry where more than one code is required in the target code set to replicate the complete meaning of the source system ('AND')


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GEMs Conversion Sample


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Why Payers use Maps

•New coverage policies •New medical review edits• New reimbursement schedules

•Contracting with providers and employers •Coverage determinations

•Plan structures •Payment determinations •Statistical report

•Fraud and abuse monitoring •Quality measurements •Claims adjudication and remediation

Why Providers use Maps

•Outdated documents and reports containing ICD-9 codes •Contracting with payers

•Lab orders need updates •New medical review edits •Quality measurements

•Medical Necessity •Data warehouse conversions


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GEMs Limitations

ICD-9-CMICD-10-CM/PCS

Transactions with any unmapped or improperly mapped codes will need to be handled manually, increasing costs and causing significant slowdown in analysis and work processes throughout for everyoneWednesday, March 20, 2013

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Financial Implications and Revenue Cost in correlation to GEMs

•Claims mapping to multiple DRGs.

•Impact on facility Case Mix Index.

•Coding and financial impact for each specialty.

•Coding effect on each physician’s claims and reporting by physician.•ICD-9 to ICD-10 PCS coding requirements by physician.

•Each claims code mapping should be viewed.

•Commercial, Medicaid and Medicare claims need to be analyzed.

•Standard analysis groups and prices all claims using the MS-DRG methodology.

•Inpatient claims will be processed using:-GEM (General Equivalence Mappings) file for ICD-9 and ICD-10-ICD-10 Software Version of the MS-DRG Grouper

•Reporting also for outpatient and physician claims.Wednesday, March 20, 2013

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•Incomplete coding may impact DRG assignment.

•Coding conflicts resolved by assigning to the higher frequency DRG may compromise reimbursement.

•ICD-10 Codes for a new concept without an ICD-9 translation now assigned to a medical MS-DRG.

•Expect further refinement to DRG assignment and reimbursement based on more discrete ICD-10 detail.


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GEMs Impact on DRG ShiftMS-DRG Level

ICD-9 Secondary Diagnosis

ICD-10 GEMs Description

DRG 621 OR proc. for obesity, no CC/MCC Wt: 1.4835 $8,901

786.09 Other dyspnea or other respiratory abnormality

R06.89 Other abnormalities of breathing

Not a CC

DRG 620 OR proc. for obesity w/ CC Wt: 1.8384 $11,030


R06.3 Periodic breathing A CC

DRG 621 Wt: 1.4835 $8,901


R06.00 Other dyspnea Not a CC


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MS-DRG Level ICD-9 Principal Diagnosis

ICD-10 GEMs Description

DRG 395 Other Digestive System Diagnoses, no CC/MCC Wt: 0.6643

$3,986

568.89 Disorders of the peritoneum

K66.8 Other specified disorders of the peritoneum

DRG 373 Major Gastrointestinal disorders & peritoneal infections w/ CC Wt: 0.8437 $5,062

568.89 Disorders of the peritoneum

K68.9 Other disorders of the retroperitoneum

DRG Shift with GEMs


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MS-DRG Level Principal Diagnosis Coding Guideline

DRG 945 Rehabilitation w/o CC/MCC Wt: 1.1273 $6,764

V57.1 Other physical therapy

(ICD-9) Follow-up codes are listed first unless a condition has recurred

on the follow-up visit

DRG 566 Diseases and Disorders of the Musculoskeletal System Wt: .9350 $5,610

I69.990 Apraxia as late effect cerebrovascular disease

(ICD-10) Z codes should not be used if treatment

is directed at the current

injury

DRG 949 Aftercare w/o CC/MCC

Wt: .5040

$3,024

Z51.89 Encounter for other

specified aftercare

This scenario if coder incorrectly uses ICD-9

Guideline

ICD-10 Coding Guidelines Impact DRG


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Backwards and Forward Mapping Translations are not equal

ICD

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R6521 Severe sepsis with shock

99592 Severesepsis

1 0 1 1 1

R6521 Severe sepsis with shock

78552 Septicshock

1 0 1 1 2

ICD-9 to ICD-10-CM Translation of Septic Shock is one to one

78552 Septic shock R6521 Severe sepsis with septic shock

ICD-10-CM Translation of the same code back to ICD-9 require a combination code

R6521 Severe sepsis with septic shock99592 Severe sepsis

78552 Septic shockWednesday, March 20, 2013

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GEMs or Cubic ZirconiumCMS and Payers know the Difference

The imperfect GEMS have a higher purpose, e.g., data analyses and

reporting at the highest level of morbidity and mortality statistics or case rates.

Providers and coders should not use them. If providers and coders attempt to code from a GEMs table, they risk errors in both coding, billing and potentially fraud. Therefore, best practice is to code only from the patient medical record and to not use the GEM conversion tables for medical coding and billing!


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Analyze Report on most-used codes

Provide Statistics to help Test TeamProvides Demographic of 9 & 10 codesAnalyze large volumes of current claim data

MapCMS GEMS/ Plan specific mappings loadedPowerful if-then rules engine for custom mappings

ConvertGenerate ICD-10 data filesUse date driven logicGenerate multiple claims based on single input claim

Test/ReportingParallel TestingRevenue NeutralityAbility to load custom Reimbursement FilesDetail breakup of Groups, Heavy Hitter Codes, Provider, Benefit Categories

GEMs


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Conversion Best Practices

Hire a Project Manager

Use the necessary ICD-10 Conversion Software Tool

Leap I-10 or HL7

(Excel Spreadsheets are hard to manage)

Dual end –to-end Testing

Outcomes analysis


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“This presentation is intended solely for educational purposes and present information of a general nature. It is not intended to guide or determine any specific individual situation and persons should consultant qualified professionals before taking specific actions. The views expressed in the presentation are those of the presenter, and not those of NCHIMA.”

Disclaimer


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References

NCHS website with GEM files/Documentation and User’s Guide

cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

GEMs files

http://www.cdc.gov/nchs/icd/icd 10cm.htm

ftp.cdc.gov/pub/Health Statistics/NCHS/Publications/ICD10CM/2013/

AMA’s website for implementing ICD-10

www.ama-assn.org/go/ICD-10


http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

icd-10 update understanding and analyzing gems...

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