Physician Practice

Practices lagging in ICD-10 training shouldn't be tempted to rely on GEMs

Physician Practice Insider, December 16, 2014

The ICD-10 implementation delay mandated by Congress this spring granted providers an extra year to prepare for the new code set, but one survey has found some organizations heading in the wrong direction.

The August 2014 survey by the Workgroup for Electronic Data Interchange (WEDI) of 324 providers, 87 vendors, and 103 health plans found that many organizations are further behind in their plans compared to the results of an October 2013 survey. One third of the respondents were from physician practices.

Approximately 50% of all providers had completed their initial ICD-10 impact assessment, according to the survey. However, three-quarters of smaller providers responded that they didn’t plan to complete their assessment until 2015 or replied ‘unknown,’ indicating they weren’t sure when they might finish.

Providers were also delaying their external testing. In the 2013 survey, approximately 60% expected to begin testing by the middle of 2014, but only 33% had begun testing by the latest survey. “Further analysis shows that for the larger providers over one-half had begun external testing, while for smaller providers most did not plan to begin external testing until 2015 or responded ‘unknown’,” according to the study.

The survey also found that while providers made progress toward plans for native ICD-10 coding—with approximately 66% planning to do so—the number of providers planning only to crosswalk from ICD-9-CM to ICD-10 has doubled. In the 2013 survey, approximately 13% responded they would only use crosswalks. That percentage grew to 25% in the latest survey. Approximately 20% said they plan to use a combination of approaches.

“This indicates progress toward native ICD-10 processing for many entities, but a greater reliance on crosswalking for others, especially among smaller providers,” the study notes.

However, using General Equivalence Mappings (GEM) to crosswalk directly from ICD-9-CM to ICD-10 is not the reason they were created.

"Most people use the GEMs as a starting point," says Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, vice president of ICD-10 education and training for AAPC in Salt Lake City. "If you try to use them for the end result, you're going to be in a lot of trouble."

Some believe that because they will still report outpatient procedures with CPT® codes after implementation, they don't have to worry about training staff to natively code in ICD-10.

"I've shared my opinion very strongly [with organizations] that even if the outpatient coders won't be using the ICD-10-PCS procedure codes, they will be required to code diagnoses in ICD-10, so at a minimum they do need the ICD-10-CM training and education," says Barbara Hinkle-Azzara, RHIA, vice president of HIM operations for HRS, based in Baltimore.

Understanding GEMs

The GEMs that are publicly available on CMS' website were developed by CMS and the CDC, along with representatives from the American Hospital Association and AHIMA.

Using the GEMs, ICD-9-CM codes can be mapped to ICD-10-CM/PCS codes—known as forward mapping—and ICD-10-CM/PCS codes can be mapped to ICD-9-CM—known as backward mapping. However, the GEMs were not created as a replacement for coding natively in ICD-10.

"The term 'crosswalk' is a bit of a misnomer, because it implies that these can be used as a one-to-one translation, but we know that's not the case," says Hinkle-Azzara.

CMS has used the GEMs for several projects, such as translating codes from the ICD-9-CM Official Guidelines for Coding and Reporting to the ICD-10-CM version and creating the ICD-10 Reimbursement Mappings. CMS used the GEMs as a starting point to create these reimbursement mappings by backward mapping ICD-10-CM/PCS codes to the most applicable ICD-9-CM diagnosis or procedure code. In instances when multiple ICD-9-CM codes were available, CMS chose the most applicable ICD-9-CM code based on Medicare data.

All ICD-10-CM/PCS codes are included in the Reimbursement Mappings, but not all ICD-9-CM codes are. CMS will not be using the Reimbursement Mappings because it is converting its systems to directly accept ICD-10-CM/PCS codes.

CMS updates the GEMs annually, though they have remained relatively stable in recent years due to the extended code freezes for ICD-9-CM and ICD-10. The first regular update to ICD-10 is scheduled for October 1, 2016. CMS intends to continue updating the GEMs for three years after ICD-10 implementation.

The danger of GEMs

Despite CMS repeatedly noting that GEMs should not be used as a replacement for natively coding in ICD-10, providers are clearly tempted to rely on them to prepare for implementation, as seen in the WEDI survey results.

However, the limitations of the GEMs can become quickly apparent. "If the concept didn't exist in ICD-9-CM, you can't capture it in ICD-10-CM by using the GEMs," says Buckholtz.

To ensure clinical data is not lost and diagnoses are reported accurately, Hinkle-Azzara recommends providers prepare for implementation by training coders to review the source documentation and natively code in ICD-10 to assign the most appropriate code and identify any potential documentation gaps.

"The GEMs have limited uses," Hinkle-Azzara says. "They lack clinical rules necessary to accurately map many codes. The result [if providers rely on them for unintended purposes] is diluted data; there's no two ways about it."

This article is adapted from Briefings on APCs.

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