November 23, 2009
GEMs — A Training Tool for Coders
By Selena Chavis
For The Record
Vol. 21 No. 22 P. 20
More zirconium than actual diamond, general equivalence mapping can help with the transition to ICD-10, but it shouldn’t be viewed as a solution.
It’s coming. In fact, the October 1, 2013, target date for the conversion to ICD-10 is now less than four years away.
That may sound like a long time, but many industry professionals suggest that organizations have much to consider on both the clinical and administrative fronts to be adequately prepared for the new coding system.
“Why is everyone talking about this now?” asks Shelley Safian, CCS-P, CPC-H, CHA, program director/instructor at Florida’s Herzing College. “The wise people will use this time … because we all know that psychologically, we all don’t like change. It needs to be a slow, gradual process.”
In light of rising fears over what the transition will mean for the average coder, many professionals believe that the General Equivalence Mapping (GEM) system may be an effective tool to assist with training and ease concerns associated with the learning curve. Developed over a three-year period by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) with input from the American Hospital Association (AHA) and the AHIMA, GEMs are designed to help with the conversion of ICD-9-CM to ICD-10-CM for a number of target audiences.
GEMs are forward and backward mappings of the coding systems, sometimes referred to as crosswalks because they provide information linking codes of one system with the other.
“The good news is that they are out there and are being packaged … so coders can compare and get their feet wet with them,” notes Rhonda Butler, CCS, CCS-P, an ICD-10 expert with 3M Health Information Systems who helped develop GEMs as part of 3M’s contract with the CMS.
However, Butler warns that there may be some confusion about how to effectively use the tool, pointing out that “getting their feet wet with them” is a much different education function than using GEMs to code after 2013.
“Many more people think they need to know GEMs than actually do,” she explains. “The average coder doesn’t need to know the grand picture of GEMs.”
Julia Croly, CPC, CPC-P, a member of the American Academy of Professional Coders’ (AAPC) ICD-10 conversion effort and its National Advisory Board, agrees, adding that she uses GEM as a reference guide. “I think during transition, it will be used for knowledge rather than solutioning,” she suggests. “I think it will be used in transition to test [a coder’s] knowledge base … just like they use encoders.”
Mapping It Out
The key difference between coding in ICD-9 vs. ICD-10 comes down to specificity. Whereas a particular diagnosis in ICD-9 may have one option for coding, there may be many choices in ICD-10.
The ICD-10 codes are also alpha-numeric—a vital change from ICD-9’s numeric outlay. There may be up to seven alpha-numeric characters, requiring billing software program changes to accommodate the additional digits, as well as extensive coder training.
Statistics reveal that 81% of ICD-10 diagnosis codes have a one-to-one relationship between the ICD-9 code, and 19% of ICD-10 diagnosis codes have more than one ICD-9 code to choose from for a mapping. Along the same lines, 82% of ICD-10 procedure codes have a one-to-one match, and 17% of ICD-10 codes have more than one ICD-9 match. There are 7,606 unique ICD-10 diagnosis codes and 14,396 unique ICD-10 procedure codes.
According to Safian, the GEM system maps the corresponding ICD-9 codes to all reasonable translation alternatives. “Sometimes there may be five options, so then [the coders] have to go into the manual,” she says.
Offering the diagnosis of Salmonella meningitis as an example, Safian points out that there is a one-to-one match—ICD-9 003.21 becomes the ICD-10 equivalent of A02.21. In the case of a pregnant patient who is spotting blood, however, the ICD-9 code becomes a choice of four different ICD-10 codes requiring greater specificity.
Coding under the former system for spotting during pregnancy only required knowledge of whether the patient was antepartum. Now, Safian says coders will also need to know what trimester of pregnancy the patient is currently in.
In another example, the ICD-9 code for a laparoscopic cholecystectomy (51.23) finds a one-to-one match with its ICD-10 equivalent (0FB44ZZ). But in the case of a simple suture of dura mater of brain, the ICD-9 code 2.11 can be mapped to three different alternatives under ICD-10.
In some cases, there is no translation between the systems, and GEMs simply point to a “no map” flag.
According to a CMS fact sheet on GEMs, the tool’s intended audience includes “coding professionals, payers, providers, medical researchers, informatics professionals, as well as any other individuals who use coded data. The GEMs can be used in converting payment systems, payment and coverage edits, risk adjustment logic quality measures, and a variety of research applications involving trend.”
Butler believes that while GEMs may be a good reference or training tool in relation to coders, there may be some confusion about just how the system is intended to benefit that audience over the long haul.
“If we are talking about the recommended uses, they are short lived,” she says, speaking directly to how coders should view the tool. “After October 1, 2013, they don’t have the luxury of thinking in terms of ‘I-9.’ They can’t become dependent on it.”
After 2013, Butler says the primary entities that will benefit from GEMs are groups such as insurance providers that need the system from a technological standpoint to translate between ICD-9 and ICD-10 for payment purposes.
“It’s essentially a way to continue the payment process,” she notes, adding that GEMs can either be used to write a program and transfer the codes into a software program or to build a map that will translate ICD-10 back to ICD-9 equivalents. “That way, they can continue to use those old legacy-based systems.”
According to Croly, the greatest advantage of GEMs will come in identifying opportunities for improvement and training before the 2013 implementation date. “It could be used as a learning tool or a confirmation tool that they are going down the right path,” she suggests.
Safian points to the 80-20 rule for most coders in physician practices in that 80% of a specialist’s practice will fall into a certain range of codes. In the same way, she notes that hospital coders often will be assigned to particular areas of specialization. GEMs can lead organizations to a range of codes used most frequently and a better understanding of documentation and specificity needs for training purposes.
“I believe GEMs are there as a teaching tool that should never replace actually using the new system,” she says, adding that coders will need to learn how to process the information from scratch. “This tool can guide you … to specifying the additional detail you are going to need to educate your clinical staff.”
The kicker to the whole process is knowing what potential documentation challenges an organization will face, Butler notes. “The question is whether the documentation is in the chart,” she says. “That’s the big one.”
Safian adds that if an organization has not instituted a formal query process for potential documentation shortages or clarification, “now is the time to implement those.”
Offering an example, Safian points to the fact that there are 12 different codes under ICD-10 for properly reporting a colonoscopy. “In order to report a colonoscopy, you are also going to need to know if the physician removed anything … and how it was removed,” she says, pointing to the need for extra detail. “The methodology is going to be a factor in choosing the right codes. This is a management issue of training that needs to be addressed.”
Not only is trying to code straight from GEMs an impractical way to approach the ICD-10 transition, it’s just “not a good way to code,” explains Butler.
“That just takes the coder farther and farther from the record [if they are just comparing ICD-9 to GEMs],” she says. “Basic coding is record by record. It only makes sense to code directly from ICD-10 after implementation.”
Butler points out that the process really does not change and that once coders are using ICD-10 on a regular basis, they will realize they do not need to rely on the GEM system for assistance. “Coders get scared when they hear that there are so many more codes,” she explains, adding that more often than not, coders discover the process is the same with just a few additional questions to be considered. “In some cases, it may be easier to code. … It may be more relevant to the real world.”
Safian agrees, adding that the process is identical to what a coder is used to doing on a daily basis. “With that said, if we can deal with the fear factor, that will help people a lot,” she says. “They need to look at GEMs as an instructional tool. … Do not expect to sit with the GEM and get all your answers.”
Even though GEMs will map to a corresponding diagnosis code or range of codes, Croly notes that sometimes a “generic” ICD-9 code will produce another “generic” ICD-10 code, lacking the greater specificity needed to adequately address the full patient picture.
As an example, she points to the general ICD-10 code for osteonecrosis (M90.5), which could show up as the generic alternative for the ICD-9 equivalent under GEMs. What a coder may not realize is that there are actually more than 30 other options for coding this particular diagnosis under ICD-10 that more clearly define the location of the ailment (see sidebar).
While it seems that GEMs should allow for quicker coding in the transition to the new system, Croly points out that it will likely have the opposite effect and reemphasizes that the coding process itself does not change. “If coders use [GEMs], it’s probably going to slow them down,” she says. “It’s an added layer.”
In other words, GEMs can be a great tool for identifying and learning the new codes, but the coder is still going to have to go through the process of looking up and matching codes with appropriate diagnoses.
It’s All Greek to Me
In its current form, Croly notes that GEMs aren’t going to mean much to the average coder. “It’s made up of flat files,” she says, pointing to the system’s technological aspects. “The average coder isn’t going to understand them.”
By definition, a flat file is a static document, spreadsheet, or textual record that typically contains data that are not structurally related. Flat files are called so because there is little that can be accomplished with the information contained in them other than reading, storing, and sending. They are typically used as a data storage method for applications and programs.
Croly believes that companies and vendors will begin to realize there is a need for making this system more user friendly and that some front-end tools will eventually begin to surface to address readability. In fact, the AAPC has developed a tool called the Code Translator, which takes the ICD-9 code and maps it to the ICD-10 code choices.
Croly points out that the purpose of the Code Translator, expected to be released soon, is to make the GEM files more user friendly and to aid coders.
— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.
The ICD-10 Difference
Experts emphasize that not all diagnosis codes will have a one-to-one match from ICD-9 to ICD-10. Julia Croly, CPC, CPC-P, a member of the American Academy of Professional Coders’ ICD-10 task force, suggests using General Equivalence Mappings (GEMs) as a reference guide and not a solution. Pointing to potential pitfalls, she notes that some diagnoses may have a “generic” match under ICD-10 but coders could miss the need for greater specificity.
For example, in the case of osteonecrosis, the ICD-9 code is 731.8, Other bone involvement in diseases classified elsewhere. Moving to ICD-10, there are more than 30 possibilities for the same diagnosis, including the following:
• M90.5 — Osteonecrosis in diseases classified elsewhere;
• M90.50 — Osteonecrosis in diseases classified elsewhere, unspecified site;
• M90.51 — Osteonecrosis in diseases classified elsewhere, shoulder;
• M90.511 — Osteonecrosis in diseases classified elsewhere, right shoulder;
• M90.512 — Osteonecrosis in diseases classified elsewhere, left shoulder;
• M90.519 — Osteonecrosis in diseases classified elsewhere, unspecified shoulder;
• M90.52 — Osteonecrosis in diseases classified elsewhere, upper arm;
• M90.521 — Osteonecrosis in diseases classified elsewhere, right upper arm;
• M90.522 — Osteonecrosis in diseases classified elsewhere, left upper arm;
• M90.529 — Osteonecrosis in diseases classified elsewhere, unspecified upper arm;
• M90.53 — Osteonecrosis in diseases classified elsewhere, forearm;
• M90.531 — Osteonecrosis in diseases classified elsewhere, right forearm;
• M90.532 — Osteonecrosis in diseases classified elsewhere, left forearm;
• M90.539 — Osteonecrosis in diseases classified elsewhere, unspecified forearm;
• M90.54 — Osteonecrosis in diseases classified elsewhere, hand;
• M90.541 — Osteonecrosis in diseases classified elsewhere, right hand;
• M90.542 — Osteonecrosis in diseases classified elsewhere, left hand;
• M90.549 — Osteonecrosis in diseases classified elsewhere, unspecified hand;
• M90.55 — Osteonecrosis in diseases classified elsewhere, thigh;
• M90.551 — Osteonecrosis in diseases classified elsewhere, right thigh;
• M90.552 — Osteonecrosis in diseases classified elsewhere, left thigh;
• M90.559 — Osteonecrosis in diseases classified elsewhere, unspecified thigh;
• M90.56 — Osteonecrosis in diseases classified elsewhere, lower leg;
• M90.561 — Osteonecrosis in diseases classified elsewhere, right lower leg;
• M90.562 — Osteonecrosis in diseases classified elsewhere, left lower leg;
• M90.569 — Osteonecrosis in diseases classified elsewhere, unspecified lower leg;
• M90.57 — Osteonecrosis in diseases classified elsewhere, ankle and foot;
• M90.571 — Osteonecrosis in diseases classified elsewhere, right ankle and foot;
• M90.572 — Osteonecrosis in diseases classified elsewhere, left ankle and foot;
• M90.579 — Osteonecrosis in diseases classified elsewhere, unspecified ankle and foot;
• M90.58 — Osteonecrosis in diseases classified elsewhere, other site; and
• M90.59 — Osteonecrosis in diseases classified elsewhere, multiple sites.