GEMS Files

Corrie Alvarez, CPC, CPC-I,

CEDC

Objectives

Why move to ICD-10-CM?

Review ICD-10 Final Rule
Understand GEMS files
Illustrate how the files work
Review practical examples

Why ICD-10-CM?

ICD-9-CM is 30 years old

Advances in Medicine and Technology
Need for more accurate data
No room for expansion

ICD-9-CM and ICD-10-CM

ICD-9-CM currently has approximately 7,000
codes while ICD
ICD-10
10 CM has 68
68,000.
000
Currently, there are approximately 4,000 ICD-9CM procedure codes which will increase to
approximately 87,000 in ICD-10 PCS.
There will be concerns about historical data and
how to gather diagnoses and procedure data
analysis when two systems exist

HIPAA ICD-10 / ANSI 5010 Overview

Today: 4010
Current HIPAA Standard Procedure
and Diagnosis Codes Electronic
T
Transaction
ti Version
V i
Not capable of handling ICD-10

Today: ICD-9
ICD-9-CM (Diagnosis)
5 digits
(e.g. 821.01 Closed Fracture
of shaft of femur)
~14,000+ unique codes

ICD-9-CM (Procedure)
3-5 digits
(e.g. 47.01 Laparoscopic
appendectomy)
~3,000 unique codes

Tomorrow:5010
Allows for ICD-10 Procedure and
Diagnosis Codes in HIPAA
Standard Electronic Transactions

Tomorrow: ICD-10
ICD-10-CM (Diagnosis)
6 alphanumeric with qualifier
(e.g. S72.344 Displaced spiral
fracture of shaft of right femur)
~69,000+ unique codes

ICD-10 PCS (Procedure)

7 alphanumeric
(e.g. ODTJ4ZZ Laparoscopic
appendectomy)
~89,000 unique codes

ICD-10 Changes
From 14,025 codes to approximately
68,000 ICD-10--CM codes
All codes have full descriptions for both
ICD-10-CM and ICD-10-PCS
ICD-9-CM
2010
14,025
14 025 codes

ICD-10-CM
2010
69,000+

Format and Structure

ICD-10 CM Format

Category

X X X

Etiology, Anatomical site, Severity

Extension

Code Set Comparison:

Diagnosis Codes

ICD-9-CM Diagnosis
g
Codes

ICD-10-CM Diagnosis
g
Codes

3-5 characters in length

Approximately 14,025 codes
First digit may be alpha (E or V) or
numeric. Digits 2-5 are numeric
Limited space for new codes
Lacks detail
Lacks laterality
Difficult to analyze data due to nonspecific codes
Codes are non-specific and do not
adequately define diagnoses needed for
medical research
Does not support interoperability because
it is not used in other countries

3-7 characters in length

Approximately 69,125 codes
Digit 1 is alpha; digit 2 and 3 are numeric;
digit 4-7 are alpha or numeric
Flexible for adding new codes
Very specific
Has laterality
Specificity improves coding accuracy and
depth of data for analysis
Detail improves the accuracy of data used in
medical research
Supports interoperability and the exchange of
health care data between other countries and
the United States

9
9

Final Rule
January 16, 2009
ICD-10-CM and ICD-10-PCS coding
g systems
y
will replace
p
the current ICD-9-CM coding system October 1, 2013
ICD-10-CM will replace the ICD-9-CM diagnosis codes
rendered in all settings
ICD-10-PCS will replace the ICD-10-CM procedure
codes rendered within the hospital inpatient setting
CPT and HCPCS will still be used

10

Final Rule
General acute care inpatient reimbursement for
Medicare patients will be based on MS-DRGs
MS DRGs
using the ICD-10
The ICD-10-CM code set is maintained by the
National Center for Health Statistics
Mapping files that allow the industry to convert
from ICD-9-CM to ICD-10-CM and ICD-10-PCS
codes
d and
d vice
i versa h
have b
been created
t d

11

What are the GEMS?

General Equivalence Mappings
National Center for Health Statistics (NCHS) and
CMS, AHIMA, AHA, 3M Health Information
Systems.
Concerns with historical data
Attempt to convert ICD-9 and ICD-10
NCHS and CMS will update annually and will
maintain for at least 3 years

12

Who Will Use Them?

Health Plans
Providers
Medical Researchers
Medical Software Vendors

13

GEMS

AKA crosswalks
Two-way translation dictionaries
Forward mapping: ICD-9 to ICD-10
Backward mapping: ICD-10 to ICD-9

Same type of mappings for ICD-10-PCS

14

How Will GEMS Be Used?

Quality measures
Research and trending
Conversion of payment systems
Coverage edits

15

GEM Details
There are actually 4 GEM files
consist of two mappings for the diagnoses
codes and two mappings for the procedure
codes;
one in which ICD-9 is the source system and
one in which ICD-10 is the source system

16

GEMS
There are quite a few ICD-9-CM and ICD10 CM codes
10-CM
d whose
h
ttranslation
l ti b
between
t
them is very straight forward and easy to
match one with another
referred to as one-to-one (1:1) match
one to one match does not necessarily
y mean
the two codes are identical it simply means
there is only one alternative

17

Diagnosis Code Mapping

ICD-9-CM
ICD
9 CM Source

ICD-10-CM
ICD
10 CM Target

783.21 Loss of
weight

R63.4 Abnormal
weight loss

18

Diagnosis Code Mapping

ICD-9-CM Source

ICD-10-CM Target
g

784.2 Swelling in
head and neck

R22.0 Localized
swelling, mass or
lump head
R22.1 Localized
swelling, mass or
lump neck

19

No Translation
ICD-10-CM
Source

ICD-9-CM Target
g

Z72. 3 Lack of
Physical Exercise

None

20

10

No Translation
ICD-9-CM

Source

89.8 Autopsy

ICD-10-PCS Target

No ICD-10 PCS
Code

21

Procedure Code Mapping

ICD-9-CM Source

96.04 Insertion of
endotracheal tube

ICD-10-PCS Target
BH17EZ Insertion
endotracheal device
into trachea via
natural or artificial
opening
BH18EZ Insertion
endotracheal device
into trachea via
natural or artificial
opening, endoscopic

22

11

No Map Field
ICD-9-CM
V64.41
V64
41
Laparoscopic
surgical procedure
converted to open
procedure
V64.42
Thoracoscopic
surgical procedure
converted to open
procedure

ICD-10-CM

No Map

None

None

23

Procedure Code Mapping

ICD-9-CM Source

ICD-10-PCS Target

51.23 Laparoscopic
cholecystecomy

FT4ZZ Resection of the

gallbladder, percutaneous
approach

24

12

Approximate Field
The approximate field with a flag of 1
i di t th
indicates
the mapping
i iis approximate
i t att
best. When the value is 0, it indicates an
exact match
Due to the increased specificity of the ICD10 codes an exact match is very difficult

25

Approximate Field
The approximate field with a flag of 1
1
indicates the mapping is approximate at
best. When the value is 0, it indicates an
exact match
Due to the increased specificity of the
ICD-10
ICD
10 codes an exact match is very
difficult

26

13

Combination Field
A 0
0 value in this field indicates a
one to one mapping
A 1 in this field indicates the
requirement of more than one code
to complete the mapping

27

Scenario Field
When the combination flag has a value of 1,
the Scenario attribute field will be populated
with a scenario number for
f each combination
of codes that make up a distinct mapping
option
Example:
If 5 ICD-9 CM codes are required to make one ICD-10-PCS code,
there will be 5 lines with the same ICD-10-PCS code, each with
different ICD-9-CM codes & each with a 1 in the comb attribute
field & a 1 in Scenario attribute field

28

14

Choice Field
Choice as an attribute field indicates
how to use each code in a mapping
that requires multiple codes

29

Summary of Flags
Each GEM has 5 Flags:
1.The approximate Flag
2. the No Map Flag
3. A flag to indicate a one to many
mapping
4 & 5. Two flags to further clarify one to
many mapping

30

15

Flat File Set Up

A flat file is a data file that contains
records with no structural relationships
Data arrangement consists of a series of
columns and rows in a tabular format
Additional knowledge is required to interpret
these flat files

31

Flat File Set Up

Source
Code

Target
Code

Approx.

No Map

Flags
Comb. Scenario

Choice

32

16

Example: Hematuria 599.70; mapping from

ICD-9-CM to ICD-10-CM with flags

ICD-9-CM
5993
5994
5995
59960
59969
5997
59970
59970
59970
59981
59982
59983
59984

ICD-10-CM
N362
N360
N368
N139
N139
R310
R311
R312
R319
N3641
N3642
N368
N368

Flags
00000
10000
10000
10000
10000
10000
10000
10000
10000
00000
00000
10000
00000

33

Diagnosis Mapping File Layout

Position

Length

Contents

ICD-9 CM Code Source

(Fill )Ch
(Filler)Character
t is
i left
l ft blank
bl k

ICD-10CM Code Target

14

(Filler)Character is left blank

15

16

17

18

19

Approximate flag
1 = Yes/On
0 = No/Off
No Map flag
1 = Yes/On
0 = No/Off
Combination Flag
1 = Yes/On
0 = No/Off
Scenario
0-9
Choice List
0-9

17

Procedure Mapping File Layout

Position

Length

Contents

ICD-10 PCS Code Source-all seven characters used

8
9

1
5

14
15

1
1

16

17

18

19

(Filler)Character is left blank

ICD-9 CM Code Target - left justified, blank filled,
no decimal
(Filler)Character is left blank
Approximate flag
1 = Yes/On
0 = No/Off
No Map flag
1 = Yes/On
0 = No/Off
Combination Flag
1 = Yes/On
0 = No/Off
Scenario
0-9
Choice List
0-9

Reimbursement Mappings
The Reimbursement Mappings were
developed by CMS in response to the
health care industry requests for a standard
reimbursement crosswalk
The Reimbursement Mappings consist of
two crosswalks:
ICD-10 CM to ICD-9 CM for diagnosis codes and
ICD-10 PCS to ICD-9 CM for procedure codes

36

18

Creation of the Reimbursement

Files
CMS used the GEMs as a starting
point by selecting the best ICD-9 CM
code that maps to each ICD-10 code
The data used to create the files may
reflect more characteristics of what
occurs in the inpatient setting than
outpatient data
37

Patterns
Code Set

Total
Numb
er of
Codes

Mapped
to a
single
ICD-9CM
code
69,101 65,767

ICD-10CM
Diagnosis
ICD-10- 71,957
71 957 69,657
69 657
PCS
Procedure

Mapped
to a two
code
cluster

Mapped
to a
three
code
cluster

Mapped
to a
four
code
cluster

Mapped
to a five
code
cluster

3,302

26

1211

583

458

36

38

19

Reimbursement Mapping File Layout

Position

Length

Contents

I-10 Code (3 to 7 characters) left justified in 8 character field. Last character in field is left
blank.

N b off I-9
Number
I 9 codes
d this
thi ICD-10
ICD 10 code
d map to.
t Values
Vl
1 to
t 5

10

First I-9 code (2 to 5 characters) left justified in a 6-character field. Last character is left blank.

16

Second I-9 code (2 to 5 characters) left justified in a 6-character field if I-10 code mapped to
two or more I-9 codes. Last character is left blank.

22

Third I-9 code (2 to 5 characters) left justified in a 6-character field if I-10 code mapped to
three or more I-9 codes. Last character is left blank

28

F
Fourth
h I-9
I 9 code
d (2 to 5 characters)
h
) left
l f justified
j ifi d in
i a 6-character
6 h
fi ld if I-10
field
I 10 code
d mappedd to
four or more I-9 codes. Last character is left blank

34

Fifth I-9 code (2 to 5 characters) left justified in a 6-character field if I-10 code mapped to five
I-9 codes. Last character is left blank

GEMS Examples
ICD-9-CM Code Description GEMS Results

Issues

810.03

There are over 24

choices for
fracture of a
clavicle, not
counting 7th
character
extenders

Fracture
Clavicle

S42.33ADisplaced
fracture of lateral end
of unspecified
clavicle, initial
encounter for closed
fracture
S42.36ANondisplac
ed fracture of lateral
end of unspecified
clavicle initial
clavicle,
encounter for closed
fracture

40

20

GEMS Examples
ICD-9-CM
Code

Description

GEMS Result

Issues

727.03

Trigger Finger

M65.30

Does not give

results for
laterality or digit

41

GEMS Examples
ICD-9-CM Code

Description

GEMS Result

Issues

362.07

Diabetic
E11.311,E09.311,
,
, Links onlyy to
macular edema
E13.311, E10.311 E11.311 Type 2
diabetes mellitus
with unspecified
diabetic
retinopathy with
macular edema.
There are many
choices available

42

21

GEMS Files
ICD-9-CM Code Description
874.9
Decapitation

GEMS Result

Issues

S11.82XA

Links to the
wrong code, this
code is for
laceration of the
neck with
foreign body,
initial encounter

43

GEMS Examples
ICD-9-CM
Code

Description

GEMS Result Issues

844.9

Shin splints

T79.6

This code is for

ischemia of
muscle

44

22

GEMS Examples
ICD-9-CM Code

Description

GEMS
Result

Issues

681.11

Abscess,
paronychia nail

L03.031L03.039

Onychia/Paronychia
is inflammation not
Cellulitis

45

Conclusion
The mappings were created to
address a number of issues a health
plan may face when dealing with two
very different sets of data such as
trending diagnoses and procedures
overtime, converting adjudication
edits, benefit determinations, etc.

46

23

 The Reimbursement Mappings allow

health p
plans to utilize ICD-10-CM/PCS
codes and map back to a single ICD-9CM code

47

Be Pro-Active
Obtain your top used ICD-9-CM codes
If your crosswalk was obtain by using the GEMS
files, you will need to verify their accuracy
This process may take several weeks,so plan
early
Inaccurate coding will result in increased denials
and delayed
y payments
p y

48

24

Thank You!
Questions?

49

25