GEMS Files Corrie Alvarez, CPC, CPC-I, CEDC

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Objectives • • • • •

Why move to ICD-10-CM? Review ICD-10 Final Rule Understand GEMS files Illustrate how the files work Review practical examples

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Why ICD-10-CM? • • • •

ICD-9-CM is 30 years old Advances in Medicine and Technology Need for more accurate data No room for expansion

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ICD-9-CM and ICD-10-CM • ICD-9-CM currently has approximately 7,000 codes while ICD ICD-10 10 CM has 68 68,000. 000 • Currently, there are approximately 4,000 ICD-9CM procedure codes which will increase to approximately 87,000 in ICD-10 PCS. • There will be concerns about historical data and how to gather diagnoses and procedure data analysis when two systems exist

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HIPAA ICD-10 / ANSI 5010 Overview Today: 4010 Current HIPAA Standard Procedure and Diagnosis Codes Electronic T Transaction ti Version V i Not capable of handling ICD-10

Today: ICD-9 ICD-9-CM (Diagnosis) 5 digits (e.g. 821.01 – Closed Fracture of shaft of femur) ~14,000+ unique codes

ICD-9-CM (Procedure) 3-5 digits (e.g. 47.01 – Laparoscopic appendectomy) ~3,000 unique codes

Tomorrow:5010 Allows for ICD-10 Procedure and Diagnosis Codes in HIPAA Standard Electronic Transactions

Tomorrow: ICD-10 ICD-10-CM (Diagnosis) 6 alphanumeric with qualifier (e.g. S72.344 – Displaced spiral fracture of shaft of right femur) ~69,000+ unique codes

ICD-10 PCS (Procedure) 7 alphanumeric (e.g. ODTJ4ZZ – Laparoscopic appendectomy) ~89,000 unique codes

ICD-10 Changes  From 14,025 codes to approximately 68,000 ICD-10--CM codes  All codes have full descriptions for both ICD-10-CM and ICD-10-PCS ICD-9-CM • 2010 • 14,025 14 025 codes

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ICD-10-CM • 2010 • 69,000+

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Format and Structure

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ICD-10 CM Format

X

X

X

Category

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X X X

Etiology, Anatomical site, Severity

X

Extension

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Code Set Comparison: Diagnosis Codes •

ICD-9-CM Diagnosis g Codes

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ICD-10-CM Diagnosis g Codes

• • •

3-5 characters in length Approximately 14,025 codes First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric Limited space for new codes Lacks detail Lacks laterality Difficult to analyze data due to nonspecific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries

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3-7 characters in length Approximately 69,125 codes Digit 1 is alpha; digit 2 and 3 are numeric; digit 4-7 are alpha or numeric Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the United States

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Final Rule January 16, 2009 • ICD-10-CM and ICD-10-PCS coding g systems y will replace p the current ICD-9-CM coding system October 1, 2013 • ICD-10-CM will replace the ICD-9-CM diagnosis codes rendered in all settings • ICD-10-PCS will replace the ICD-10-CM procedure codes rendered within the hospital inpatient setting • CPT and HCPCS will still be used

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Final Rule • General acute care inpatient reimbursement for Medicare patients will be based on MS-DRGs MS DRGs using the ICD-10 • The ICD-10-CM code set is maintained by the National Center for Health Statistics • Mapping files that allow the industry to convert from ICD-9-CM to ICD-10-CM and ICD-10-PCS codes d and d vice i versa h have b been created t d

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What are the GEMS? • General Equivalence Mappings • National Center for Health Statistics (NCHS) and CMS, AHIMA, AHA, 3M Health Information Systems. • Concerns with historical data • Attempt to convert ICD-9 and ICD-10 • NCHS and CMS will update annually and will maintain for at least 3 years

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Who Will Use Them? • • • •

Health Plans Providers Medical Researchers Medical Software Vendors

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GEMS • • • •

AKA “crosswalks” Two-way translation dictionaries Forward mapping: ICD-9 to ICD-10 Backward mapping: ICD-10 to ICD-9

• Same type of mappings for ICD-10-PCS

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How Will GEMS Be Used? • • • •

Quality measures Research and trending Conversion of payment systems Coverage edits

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GEM Details • There are actually 4 GEM files – consist of two mappings for the diagnoses codes and two mappings for the procedure codes; • one in which ICD-9 is the source system and • one in which ICD-10 is the source system

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GEMS • There are quite a few ICD-9-CM and ICD10 CM codes 10-CM d whose h ttranslation l ti b between t them is very straight forward and easy to match one with another – referred to as “one-to-one” (1:1) match – one to one match does not necessarily y mean the two codes are identical it simply means there is only one alternative

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Diagnosis Code Mapping ICD-9-CM ICD 9 CM Source

≈

ICD-10-CM ICD 10 CM Target

783.21 Loss of weight

≈

R63.4 Abnormal weight loss

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Diagnosis Code Mapping ICD-9-CM Source 

≈

ICD-10-CM Target g

784.2 Swelling in head and neck

≈

R22.0 Localized swelling, mass or lump head R22.1 Localized swelling, mass or lump neck

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No Translation ICD-10-CM Source 

≠

ICD-9-CM Target g

Z72. 3 Lack of Physical Exercise

≠

None

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No Translation ICD-9-CM 

Source

89.8 Autopsy

≠

ICD-10-PCS Target

≠

No ICD-10 PCS Code

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Procedure Code Mapping ICD-9-CM Source  96.04 Insertion of endotracheal tube

≈ ≈

ICD-10-PCS Target ØBH17EZ Insertion endotracheal device into trachea via natural or artificial opening ØBH18EZ Insertion endotracheal device into trachea via natural or artificial opening, endoscopic

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No Map Field ICD-9-CM V64.41 V64 41 Laparoscopic surgical procedure converted to open procedure V64.42 Thoracoscopic surgical procedure converted to open procedure

ICD-10-CM

No Map

None

1

None

1

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Procedure Code Mapping ICD-9-CM Source 

≈

ICD-10-PCS Target

51.23 Laparoscopic cholecystecomy

≈

ØFT4ZZ Resection of the gallbladder, percutaneous approach

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Approximate Field • The approximate field with a flag of “1” i di t th indicates the mapping i iis approximate i t att best. When the value is “0”, it indicates an exact match • Due to the increased specificity of the ICD10 codes an exact match is very difficult

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Approximate Field • The approximate field with a flag of “1” 1 indicates the mapping is approximate at best. When the value is “0”, it indicates an exact match • Due to the increased specificity of the ICD-10 ICD 10 codes an exact match is very difficult

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Combination Field • A “0” 0 value in this field indicates a one to one mapping • A “1” in this field indicates the requirement of more than one code to complete the mapping

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Scenario Field • When the combination flag has a value of “1”, the Scenario attribute field will be populated with a scenario number for f each combination of codes that make up a distinct mapping option – Example: If 5 ICD-9 CM codes are required to make one ICD-10-PCS code, there will be 5 lines with the same ICD-10-PCS code, each with different ICD-9-CM codes & each with a “1” in the comb attribute field & a “1” in Scenario attribute field

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Choice Field • Choice as an attribute field indicates how to use each code in a mapping that requires multiple codes

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Summary of Flags • Each GEM has 5 Flags: 1.The “approximate” Flag 2. the “No Map” Flag 3. A flag to indicate a one to many mapping 4 & 5. Two flags to “further clarify one to many” mapping

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Flat File Set Up • A flat file is a data file that contains records with no structural relationships – Data arrangement consists of a series of columns and rows in a tabular format – Additional knowledge is required to interpret these flat files

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Flat File Set Up Source Code

Target Code

Approx.

No Map

Flags Comb. Scenario

Choice

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Example: Hematuria 599.70; mapping from ICD-9-CM to ICD-10-CM with flags • • • • • • • • • • • • • •

ICD-9-CM 5993 5994 5995 59960 59969 5997 59970 59970 59970 59981 59982 59983 59984

ICD-10-CM N362 N360 N368 N139 N139 R310 R311 R312 R319 N3641 N3642 N368 N368

Flags 00000 10000 10000 10000 10000 10000 10000 10000 10000 00000 00000 10000 00000

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Diagnosis Mapping File Layout Position

Length

Contents

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5

ICD-9 CM Code Source

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1

(Fill )Ch (Filler)Character t is i left l ft blank bl k

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7

ICD-10CM Code Target

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1

(Filler)Character is left blank

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1

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1

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1

18

1

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1

Approximate flag 1 = Yes/On 0 = No/Off No Map flag 1 = Yes/On 0 = No/Off Combination Flag 1 = Yes/On 0 = No/Off Scenario 0-9 Choice List 0-9

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Procedure Mapping File Layout Position

Length

Contents

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7

ICD-10 PCS Code Source-all seven characters used

8 9

1 5

14 15

1 1

16

1

17

1

18

1

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(Filler)Character is left blank ICD-9 CM Code Target - left justified, blank filled, no decimal (Filler)Character is left blank Approximate flag 1 = Yes/On 0 = No/Off No Map flag 1 = Yes/On 0 = No/Off Combination Flag 1 = Yes/On 0 = No/Off Scenario 0-9 Choice List 0-9

Reimbursement Mappings • The Reimbursement Mappings were developed by CMS in response to the health care industry requests for a standard reimbursement crosswalk • The Reimbursement Mappings consist of two crosswalks: – ICD-10 CM to ICD-9 CM for diagnosis codes and – ICD-10 PCS to ICD-9 CM for procedure codes

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Creation of the Reimbursement Files • CMS used the GEMs as a starting point by selecting the best ICD-9 CM code that maps to each ICD-10 code • The data used to create the files may reflect more characteristics of what occurs in the inpatient setting than outpatient data 37

Patterns Code Set

Total Numb er of Codes

Mapped to a single ICD-9CM code 69,101 65,767

ICD-10CM Diagnosis ICD-10- 71,957 71 957 69,657 69 657 PCS Procedure

Mapped to a two code cluster

Mapped to a three code cluster

Mapped to a four code cluster

Mapped to a five code cluster

3,302

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6

0

1211

583

458

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Reimbursement Mapping File Layout Position

Length

Contents

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I-10 Code (3 to 7 characters) left justified in 8 character field. Last character in field is left blank.

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N b off I-9 Number I 9 codes d this thi ICD-10 ICD 10 code d map to. t Values Vl 1 to t 5

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First I-9 code (2 to 5 characters) left justified in a 6-character field. Last character is left blank.

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Second I-9 code (2 to 5 characters) left justified in a 6-character field if I-10 code mapped to two or more I-9 codes. Last character is left blank.

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Third I-9 code (2 to 5 characters) left justified in a 6-character field if I-10 code mapped to three or more I-9 codes. Last character is left blank

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F Fourth h I-9 I 9 code d (2 to 5 characters) h ) left l f justified j ifi d in i a 6-character 6 h fi ld if I-10 field I 10 code d mappedd to four or more I-9 codes. Last character is left blank

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Fifth I-9 code (2 to 5 characters) left justified in a 6-character field if I-10 code mapped to five I-9 codes. Last character is left blank

GEMS Examples ICD-9-CM Code Description GEMS Results

Issues

810.03

There are over 24 choices for fracture of a clavicle, not counting 7th character extenders

Fracture Clavicle

S42.Ø33ADisplaced fracture of lateral end of unspecified clavicle, initial encounter for closed fracture S42.Ø36ANondisplac ed fracture of lateral end of unspecified clavicle initial clavicle, encounter for closed fracture

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GEMS Examples ICD-9-CM Code

Description

GEMS Result

Issues

727.03

Trigger Finger

M65.30

Does not give results for laterality or digit

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GEMS Examples ICD-9-CM Code

Description

GEMS Result

Issues

362.07

Diabetic E11.311,E09.311, , , Links onlyy to macular edema E13.311, E10.311 E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema. There are many choices available

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GEMS Files ICD-9-CM Code Description 874.9 Decapitation

GEMS Result

Issues

S11.82XA

Links to the wrong code, this code is for laceration of the neck with foreign body, initial encounter

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GEMS Examples ICD-9-CM Code

Description

GEMS Result Issues

844.9

Shin splints

T79.6

This code is for ischemia of muscle

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GEMS Examples ICD-9-CM Code

Description

GEMS Result

Issues

681.11

Abscess, paronychia nail

L03.031L03.039

Onychia/Paronychia is inflammation not Cellulitis

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Conclusion • The mappings were created to address a number of issues a health plan may face when dealing with two very different sets of data such as trending diagnoses and procedures overtime, converting adjudication edits, benefit determinations, etc.

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• The Reimbursement Mappings allow health p plans to utilize ICD-10-CM/PCS codes and map back to a single ICD-9CM code

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Be Pro-Active • Obtain your top used ICD-9-CM codes • If your crosswalk was obtain by using the GEMS files, you will need to verify their accuracy • This process may take several weeks,so plan early • Inaccurate coding will result in increased denials and delayed y payments p y

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Thank You! • Questions?

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