ICD-10 Update Understanding and Analyzing GEMs...
Transcript of ICD-10 Update Understanding and Analyzing GEMs...
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"ICD-10 Update Understanding and Analyzing GEMs"
March 10, 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.
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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
786.09 Other dyspnea or other respiratory abnormality
R06.3 Periodic breathing A CC
DRG 621 Wt: 1.4835 $8,901
786.09 Other dyspnea or other respiratory abnormality
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
-10
cod
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ICD
-10
C
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De
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ICD
-9co
de
ICD
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od
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De
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Ap
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ag
No
Map
Fl
ag
Co
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inat
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Fla
g
Sce
nar
io
Ch
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e L
ist
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
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