3/20/2013. "ICD-10 Update Understanding and Analyzing GEMs" March 10, 2013

Transcription

1 "ICD-10 Update Understanding and Analyzing GEMs" March 10,

2 Leola Burke MHSA, CCS AHIMA-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. 2

3 Learning Objectives 1. What are GEMs and how are they used? 2. Understand how GEMS impact ICD Leap I-10 & HL7 tools and uses for ICD-10 conversion. Payer and Provider perspective 4. Code Mapping Tools vs. Crosswalks from GEMs A. Reference Maps and Purpose Built Maps B. 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 Implications B. Revenue Cost C. GEMs translations impact DRG shifts from ICD-9 to ICD Obtain helpful hints on what you should be doing in your institution. A. Data map project planning and execution B. Conversion Best Practices 3

4 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 4

5 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 5

6 The ICD-10 Conversion Tools Leap I-10 & HL7 Impact on Provider Departments Finance Revenue Cycle Quality and Clinical IT Data Warehouse 6

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8 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 8

9 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 9

10 PURPOSE-BUILT MAPS REIMBURSEMENT MAPS OUTPATIENT-FOCUSED MAPS PUBLIC HEALTH-FOCUSED MAPS RESEARCH-FOCUSED MAPS OTHER MAPS 10

11 REFERENCE MAPS ICD-9-CM Forwards ICD-10-CM/PCS ICD-10-CM/PCS Backwards ICD-9-CM Forward maping-icd-9 to ICD-10 GEMs Target system Source system 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 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) 11

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13 GEMs Conversion Sample ICD-9-CM ICD-10-CM S72.009A Fracture of unspecified part of neck of femur, closed Fracture of unspecified part of neck of femur, closed Forwards Fracture of unspecified part of neck of unspecified femur, initial encounter for closed fracture S72.001A Fracture of unspecified part of neck of right femur, initial encounter for closed fracture Backwards Or S72.002A Fracture of unspecified part of neck of left femur, initial encounter for closed fracture Or S72.009A Fracture of unspecified part of neck of unspecified femur, initial encounter for closed fracture 13

14 Table 1 Percentages of Types of Matches 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 % % 1-to-1 Approx Match with 1 choice 82.6 % 49.1 % 1-to-1 Approx Match with Multiple Choices 1-to-Many Match with 1 Scenario 1-to-Many Match with Multiple Scenario 4.3 % 18.7 % 6.6 % 2.1 % 0.2 % 2.9 % 14

15 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. 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? 15

16 Additional Information Specified in Flags Read as 1=On, 0=Off Three different flags Approximate No Map Combination 16

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19 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') 19

20 GEMs Conversion Sample 20

21 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 21

22 GEMs Limitations ICD-9-CM ICD-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 everyone 22

23 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. 23

24 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. 24

25 GEMs Impact on DRG Shift MS-DRG Level ICD-9 Secondary Diagnosis ICD-10 GEMs Description DRG 621 OR proc. for obesity, no CC/MCC Wt: $8, Other dyspnea or other respiratory abnormality R06.89 Other abnormalities of breathing Not a CC DRG 620 OR proc. for obesity w/ CC Wt: $11, Other dyspnea or other respiratory abnormality R06.3 Periodic breathing A CC DRG 621 Wt: $8, Other dyspnea or other respiratory abnormality R06.00 Other dyspnea Not a CC 25

26 DRG Shift with GEMs MS-DRG Level ICD-9 Principal Diagnosis ICD-10 GEMs Description DRG 395 Other Digestive System Diagnoses, no CC/MCC Wt: $3, Disorders of the peritoneum K66.8 Other specified disorders of the peritoneum DRG 373 Major Gastrointestinal disorders & peritoneal infections w/ CC Wt: $5, Disorders of the peritoneum K68.9 Other disorders of the retroperitoneum 26

27 ICD-10 Coding Guidelines Impact DRG MS-DRG Level Principal Diagnosis Coding Guideline DRG 945 Rehabilitation w/o CC/MCC Wt: $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 DRG 949 Aftercare w/o CC/MCC Wt:.5040 $3,024 I Apraxia as late effect cerebrovascular disease Z51.89 Encounter for other specified aftercare (ICD-10) Z codes should not be used if treatment is directed at the current injury This scenario if coder incorrectly uses ICD-9 Guideline 27

28 ICD-10 code ICD-10 Code Description ICD-9 code ICD-9 Code Description Approx Flag No Map Flag Combinatio n Flag Scenario Choice List 3/20/2013 Backwards and Forward Mapping Translations are not equal R6521 Severe sepsis with shock Severe sepsis R6521 Severe sepsis with shock Septic shock ICD-9 to ICD-10-CM Translation of Septic Shock is one to one 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 shock Severe sepsis Septic shock 28

29 GEMs or Cubic Zirconium CMS 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! 29

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31 Analyze Report on most-used codes Provide Statistics to help Test Team Provides Demographic of 9 & 10 codes Analyze large volumes of current claim data Map CMS GEMS/ Plan specific mappings loaded Powerful if-then rules engine for custom mappings GEMs Test/Reporting Parallel Testing Revenue Neutrality Ability to load custom Reimbursement Files Detail breakup of Groups, Heavy Hitter Codes, Provider, Benefit Categories Convert Generate ICD-10 data files Use date driven logic Generate multiple claims based on single input claim 31

32 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 32

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34 Disclaimer 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. 34

35 References NCHS website with GEM files/documentation and User s Guide cdc.gov/nchs/about/otheract/icd9/icd10cm.htm GEMs files 10cm.htm ftp.cdc.gov/pub/health Statistics/NCHS/Publications/ICD10CM/2013/ AMA s website for implementing ICD