A General Equivalence Mapping (GEM) system offers the best industry-wide standard currently available for the forward and backward mapping of ICD – 10 Codes. GEMs can be practically applied as long as clinicians remain aware of their limitations, use them as a starting point, and receive ICD-10 training and education.
A GEM contains an alphabetical index to entries, classification system for procedures, and the appropriate code numbers. The major difference is that GEMs provide clinicians with the ability to forward map from ICD-9 to ICD-10 codes, and backward map from ICD-10 to ICD-9 coding.
An alphabetical list provides the starting point to begin a search for the appropriate code. Just as the words in a language translation guide can contain multiple meanings, the same is true of a GEM. When the index is accessed, it will return as many related items as possible. It’s up to the clinician to narrow the parameters and choose the appropriate code meaning.
A GEM will return a source code for ICD-10 and ICD-9, along with “flags” that are divided into different categories. Flag identify if the system has identified an approximate, combination or no mapping equivalent. A scenario and choice list are also available to provide more information for combination possibilities and the choice list provides alternatives for a combination entry.
Many terms, procedures and concepts have been changed or included in other categories. Adjunct codes are included to provide additional information about a specific procedure and clinicians may be faced with a combination of codes that must be used to identify a specific procedure.
The GEM results will vary depending upon the entity that created it. Additional options are available to help clinicians narrow the data for further specificity, along with instructional notes to help clarify a patient’s particular situation. GEM mapping between ICD – 10 sets isn’t a mirror copy and there will be discrepancies.
Numerous GEMs exist from multiple sources and clinicians would do well to examine the GEM from their preferred source to ascertain which would be more beneficial and the most applicable within their practice. GEMs return a variety of potentially applicable results for each situation and some are more helpful than others in a particular practice environment.
The number of new codes, greater specificity and multiple options makes the documentation process much more involved, time-consuming and frustrating for clinicians. Searches will result in multiple options that must be examined in-depth to create a match that accurately represents the illness or injury, the type of encounter and the specifics related to an individual patient.
Coders and billers will be using coding books and software systems to make their conversions and many have argued that it may be easier, quicker and more convenient for clinicians to do the same. A GEM can literally return thousands of results for a single conversion query. GEMS are meant to be a short-term solution until clinicians become fluent with the ICD – 10 coding system or design their own crosswalk system.
Utilizing a GEM system will help clinicians ease into the ICD-10 transition, but they should be aware that it isn’t a magic wand or a one-size-fits-all solution. It offers possibilities, potential and helps bridge the gap in coding, but isn’t a definitive solution.
The ability to backward and forward code is the primary attribute and advantage of a GEM system. They’re essentially reference guides that can help clinicians during the ICD-10 transitional period, but should be combined with the clinician’s expert judgment.
A General Equivalency Mapping (GEM) system is available to assist clinicians determine the correct coding options in the ICD-10 system. It’s a necessary and useful tool, but one that has distinct limitations. It provides no substitute for real training. A GEM is a general purpose tool and wasn’t originally developed for coding. It was a means of analyzing data and conducting research and studies.
GEM is a tool that can be used by clinicians to conduct searches and reverse searches to identify the correct ICD-10 codes in their practice. Translations and conversions can be done between either coding system to the other. Translating ICD-9 to ICD-10 is known as forward mapping, while ICD-10 to ICD-9 is called backward mapping. Searches will turn up approximate matches, possible combinations, and potential scenarios from which to choose and search for more data.
There are multiple versions available that have been created by vendors and professional organizations. Versions are available from the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), along with many vendors of EMR software systems. The ease of use will be determined by multiple variables that include the developer, logic and programming used.
The results that the GEM returns are dependent upon the creating entity. Clinicians will receive entirely different coding options depending upon which GEM they’re using. The sheer volume of codes in ICD-10, combined with those that didn’t exist in the old system, means that a given GEM won’t always return the best matches or choices.
The chance of a one-to-one match is very slim, and in certain circumstances the GEM may offer none at all. All search features aren’t created equal and clinicians may find they have to try multiple search terms before the GEM returns any results at all.
It’s imperative that practitioners remember that GEMs aren’t designed to be an exact converter within a clinical setting and even an “exact match” may only be an approximation. Other coding difficulties may arise when differentiating between an initial encounter and a subsequent encounter. Some ICD-10 codes may not offer lateral solutions, which means practitioners will have to create the data themselves.
The imperfections of GEMs can have a significant impact on revenues for practices, making it imperative that clinicians bill and code at the highest possible level whenever practical and prudent. GEM results may not provide an accurate reflection of the clinician’s intent or care episodes.
Any unmapped codes that are encountered will present additional challenges for overworked practitioners struggling to adapt to a new code set and maintain revenues. Examples that reflect no translation between codes are surgical instruments, cardiovascular devices and autopsy. While the latter two are unlikely to arise in the average practice, it still points out the limitations of a typical GEM.
A GEM is a tool that provides a starting point for clinicians and is no substitute for ICD-10 training and education. The GEM can’t think or factor in the many aspects that practitioners must consider when diagnosing and treating a patient. For that, clinicians must rely on their training and unique experience.
Crosswalks and mapping are terms that clinicians will be hearing a lot about when trying to ascertain the correct translation of an ICD-9 code into the new ICD-10 code system. Mapping and crosswalk tools are included with the ICD-10 codes to help clinicians covert the old codes with which they’re familiar to the new code set. The crosswalks will be maintained for three years past the official ICD-10 implementation date of Oct. 1, 2014.
The mapping ability is a valuable tool, but practitioners shouldn’t be tempted to use it as a substitute for the appropriate training. There will be many look up entries that return multiple results and practitioners must rely on their training, experience and common sense to identify the correct ICD-10 code to use. The crosswalks are searchable and will return multiple choices. Mapping will lead to an alphabetic list, then to tabular listings for further data.
Due to the greater specificity in ICD-10 codes, there will be extremely few exact matches between the two coding systems when they perform a search, but practitioners will find a wealth of approximate matches. The mapping tools included in the new codes provides medical professionals with a dictionary for translation and a starting point from which to work.
When no match is located, clinicians can perform searches that will lead to a multitude of potential coding options. A single translation can lead to any number of matches with additional possibilities to explore to create an accurate description of the condition. ICD-10 codes come with expanded possibilities for each condition. Consequently, there will be few exact matches and a single crosswalk for every situation just isn’t possible.
Combinations There will be multiple translation choices and clinicians must go further into the system to determine which code best reflects the immediate situation. The increased specificity of the coding set will often return multiple options. Depending upon the situation, clinicians can utilize up to 12 codes if needed to accurately describe a patient’s illness, disease or injury.
It’s possible to obtain the appropriate ICD-10 codes through reverse matching, but it’s important to remember that even when only one match is located, it won’t be a complete equivalent to the previous ICD-9 code. Clinicians will need to delve deeper to establish an exact match. Converting codes from ICD-10 to ICD-9 is backward mapping and one way to ascertain the correct code conversion.
There will be times when no match can be found and the mapping tool will provide a clinician with multiple scenarios, each with its own set of variations and parameters. Choice lists provide professionals with additional determination tools.
Clinicians will find very few exact matches when converting ICD-9 to ICD-10 codes. If a search turns up only one alternative, it’s considered a one-to-one match. However, practitioners should exercise caution, as the return of a single match doesn’t automatically mean the two codes are identical.
A much more common occurrence will be a return of no matches due to the new concepts expressed in the ICD-10 codes. The new codes may express multiple results for a single ICD-9 code and vice versa. The crosswalk search tool isn’t perfect or infallible. In some instances, clinicians will need to try different search terms to navigate the system and find the desired information.
Crosswalks and mapping tools provide clinicians with a bi-directional dictionary of coding options, but much like a foreign language, there will be times when a particular concept, illness, disease or injury won’t have an exact translation. Alternately, a search may return multiple possibilities. In these instances, the experience, expertise and training of the clinician will be the determining factors.
(What’s Going to be Toughest to Learn – External Causes)
Remembering some of the changes that will take place as a result of the transition to ICD-10 will come quickly, but documentation requirements are a major issue for clinicians. The greater specificity of the ICD-10 codes allows for greater accuracy, but it increases clinician documentation requirements by 15 percent.
Some of the differences include codes that include place holders on documentation forms for future needs. In the current healthcare climate, payers will want to know if another entity may be responsible for paying the costs. They’re going to examine each claim closer, making it essential that clinicians are as specific as possible. It’s estimated that 65 percent of a practitioner’s notes won’t be specific enough.
One of the most difficult facets of the new codes is the way documentation is divided. There are four parts and external injury will cause the most frustration and be the hardest to remember. The external causes portion of the documentation should be a primary focus for practitioners. New documentation requirements want very exact information about the external causes of where and how an injury took place.
General Equivalency Mapping (GEM) was created by the National Center for Health Statistics to make the documentation task easier, but the system isn’t perfect. GEM is linked to all the various code alternatives for a given instance, and a single search can return as many as 2,500 responses. Other times, a compound word search will turn up nothing, while a single word will result in what the clinician wants.
GEM displays approximate matches and combinations through an alphabetic list first and then to a tabular listing from there. Practitioners will always want to wind up at the tabular section. There is always the “Not Elsewhere Classifiable” or “Not Otherwise Specified” category, but many clinicians anticipate problems with payers if either designation is used, considering the push for greater specificity.
Many payers are under the assumption that the implementation of ICD-10 codes automatically means that there’s a specific and corresponding code for every patient issue. This isn’t the case and there will be times when those two designations will be the only available options to use.
Disease classifications and categories have received some restructuring and classification of some conditions is different from what clinicians have become accustomed. Injury groups are now classified by specific locations on the body. Practitioners will find that some diseases that were lumped together now have their own separate chapters.
Clinicians should always endeavor to code at the highest level of specificity and detail, but avoid coding for a probable or suspected diagnosis. Coding should only be completed for all the symptoms that can be documented. Acute conditions should be listed before chronic issues if both exist. In some instances, a bilateral code doesn’t exist in which case clinicians will be required to do this separately.
Coding requirements with ICD-10 are more stringent and will require considerably more effort on the part of clinicians during the documentation process. The learning curve will lead to an inevitable loss of productivity at first. Practitioners should be prepared for this and book patient appointments accordingly. Productivity and efficiency will return to normal levels as all concerned become more familiar with the new ICD-10 coding requirements.
(Do You Need to Maintain Both Code Sets in Your Practice – Yes)
Even though everyone will be using ICD-10 codes after Oct. 1, 2014 if they want to get paid, clinicians won’t quite be finished with ICD-9. Patient records prior to ICD-10 implementation must be transitioned to the new coding system. There will be coding, form and procedural changes and there are sure to be glitches along the way. With forethought, planning and understanding, the changeover can proceed easier than many might anticipate.
Clinicians and billers will have new codes to use and new standards they must implement to adhere to HIPAA regulations. Multiple changes will take place over a very short time that will be stressful. There are strategies that can be used to accomplish all the target goals that don’t require an inordinate amount of effort, excessive overtime, and maintains HIPAA compliance.
For the smoothest transition, clinicians will need patient demographic information and the means to access it at will as they make the change from their old methods to the new EMR systems capable of handling all the new codes. To maintain HIPAA compliance, sensitive data can be stored on-site or in the cloud, providing that necessary security measures are in place.
All new patient information will be coded using ICD-10. Importing ICD-9 into the data into the new coding format for existing patients will take some time, but clinicians will find that as information is transferred and existing patients continue their care, overlaps will become apparent. Practice owners will need to maintain both coding systems for a time to ensure the complete transfer of patient data.
To facilitate the initiation of ICD-10, some EMRs have automatic crosswalks that will convert the coding. To ensure compliance, it’s essential that clinicians contact the clearinghouses and payers they work with and run sufficient testing to make sure all systems can communicate with each other. Each practice should make an effort to practice with converting ICD-9 to ICD-10 to familiarize themselves with its nuances before the official implementation date.
HIPAA version 5010 is the new standard for conducting electronic transactions to ensure patient privacy is maintained. It provides a platform for the use of ICD-10 coding. Practices and billers must implement the new HIPAA 5010 standards before ICD-10 codes can be utilized.
The upgrade to version 5010 was essential, as the old systems couldn’t use or accommodate the greatly expanded code set. HIPPA 5010 applies to “covered entities” that includes payers, providers, clearinghouses and health plan carriers. They all must upgrade to the new standards if they submit claims for reimbursement, transmit patient information, track claim status and verify coverage eligibility.
Clinicians should be aware that there are a couple of potential exceptions when the use of ICD-9 codes may still apply. Those are Workers Compensation and personal injury claims. The Affordable Health Care Act regulations continue to evolve and future legislation may change to encompass those two entities under ICD-10 coding.
The use of both coding systems allows practices to test and troubleshoot any intercommunication problems with payers and providers within its network. The testing process can identify areas where clinicians may need more training in appropriate documentation and provides valuable coding practice for clinicians and billers.
Practitioners aren’t alone – there are numerous sources of online assistance. Free training and resources are available on websites that include Medicare, the American Health Information Management Association (AHIMA), and the American Academy of Professional Coders (AAPC). The Find-A-Code application is also available that offers crosswalks, lookups and tools to simplify coding.
The implementation of ICD-10 codes will have a financial impact on all practices. Practitioners will need to prepare for situations ranging from software errors that prevent reimbursements to the cost of staff training.
This requires a strategic plan that addresses the potential for multiple problems that will directly affect a clinic’s financially security and well-being.
Maintain Cash Reserves – Plan Ahead
A practice’s cash flow depends on coders/billers obtaining the best turnaround times on claims and that may not happen in the early months of ICD-10 implementation.
The reimbursement process will undoubtedly experience slow-downs and clinicians would do well to have sufficient cash reserves on hand to pay the bills and staff during the growing pains the new system is sure to suffer.
It’s best to acquire a business line of credit or a business credit card with a 0% APR for six to nine months to help tide over the first few months after ICD-10 is enforced.
Training And Education Essentials – Invest in Resources
Some practice owners will be fortunate to have staff training provided by vendors. Those who aren’t will be required to locate competent contractors who can provide the specialized training and education required for the implementation.
Everyone within the practice will require training. This includes the billers/coders as well as clinicians, who will need to modify clinical documentation to justify the increased specificity with the ICD-10 coding system.
Without enough training, bills will keep coming back to practitioners to fix, which will delay the entire payment process.
In-House Or Outsourced Billing – Examine Pros and Cons
Practitioners who are considering outsourcing will want to weigh the costs of training for in-house services against hiring an outside firm to handle those duties.
Coders/billers will need substantial training to minimize the disruption of reimbursements.
Experienced billers/coders are already in short supply and it may be better for the practice financially to hire a specialist who has already undergone training.
The Impact Of Security Vulnerabilities – Protect Data
Maintaining security is a very real concern, especially with the array of potential problems surrounding the transition.
Ensuring the security of patient information may include the purchase and installation of security software, while others may incur additional costs from vendors who are responsible for the system’s integrity.
Mistakes, oversights or compliance issues can cost a practice dearly.
Prepare for the Threat Of RAC Audits – Maintain Compliant Documentation
No one wants to hear that they’re the target of a Recovery Audit Contractor (RAC). ICD-10 implementation errors could appear as an attempt at fraud or abuse, causing a stain on a clinician’s reputation and disruption of the practice’s operation.
The best way for a clinic to be prepared is for the clinician to improve their documentation standards with the increased specificity that is necessary to justify the use of the new ICD-10 codes.
A RAC intervention is a lengthy and costly process for a private practice owner. In fact, it has the potential to drive a practice out of business.
The implementation of ICD-10 coding will take a financial toll on practices of all sizes. Preparing for the transition requires that clinicians use all their deductive skills to identify areas where the coding change will have a financial effect and plan for every contingency.