ICD-10 GEM May not be Flawless

chris.schremser1But it’s Still Highly Valuable

Chris Schremser, Chief Technology Officer, IT Enterprise Infrastructure, ZirMed.

With the mandatory ICD-10 deadline little more than a year away, healthcare organizations are understandably looking for ways to ease the transition, speed up the learning process, minimize associated time and labor costs, and avoid potential claim rejections and delayed reimbursements after the go-live date.

The need to learn a very different and more complex coding system, coupled with the necessity of running both ICD-9 and ICD-10 in tandem until all cases logged before the deadline have been fully closed and paid for—which could take months or years—raises an interesting question:

What if there were a way to automate the translation of ICD-9 codes into their ICD-10 equivalents and vice versa?

While such forward and backward mapping can’t be done flawlessly for reasons we’ll discuss in a moment, crosswalk tools exist right now that come very close.

Known as ICD-10 General Equivalent Mapping (GEM) tools, they can be an invaluable, even indispensable, part of your ICD-10 toolkit, as long as you understand what they can do—and what they can’t.

The limitations of GEM tools derive from the inherent differences between the ICD-9 and ICD-10 code sets. Put simply, ICD-10 is much more precise and specific than ICD-9, which leads to almost five times as many diagnosis codes—14,000 for ICD-9-CM (clinical modification) vs. 69,000 for ICD-10-CM. Other differences include ICD-10-CM’s use of three-to-seven character alphanumeric codes, the need to indicate laterality (right or left side of body) in codes, and the more precise way excludes notes are defined in the new code set.

As a result, there’s no straightforward, one-to-one relationship between ICD-9 and ICD-10 codes, and thus no way for a software tool to enable you to simply punch in an ICD-9 code and have its ICD-10 equivalent pop up automatically. You may occasionally get an accurate one-to-one translation while using a mapping tool, but most often you’ll get a list of likely candidates, maybe a few, maybe 10 or more.

Nevertheless, that narrowing down is a huge help in and of itself—it’s a lot easier to wade through even 50 codes than through 69,000. It also makes the process of learning the new coding system much less overwhelming and intimidating, because it breaks the information down to a more digestible level.

But there’s another issue you need to be careful about as well, particularly during forward mapping. The ICD-10 code you need will almost always be on the list of equivalent codes generated by the mapping tool (particularly when only one code comes up), but there’s no absolute guarantee, especially if the diagnosis is new, unusual, or complex.

However, even in cases where the code you need isn’t listed by the crosswalk tool, you may find that seeing codes that come close but aren’t quite right helps you identify the correct one more quickly. To minimize the chances of selecting the wrong code and speed up finding the right one, be sure to choose an ICD-10 GEM tool that doesn’t just list codes, but also automatically includes a brief description of each one.

In short, while an ICD-10 General Equivalent Mapping (GEM) tool doesn’t replace the need to learn the new codes and use careful, informed diagnostic judgment in the coding process, it can save your organization time and money while making things easier for everyone. It may not be flawless, but it’s too valuable to leave on the table.

Visit ZirMed at the MGMA Annual Conference in San Diego, October 6-9.
Exhibit Booth #607.