Posted by admin on July 2, 2011
We were told that validation of the GEMs is occurring as part of the conversion of the current ICD-9-CM-based Medicare Severity Diagnosis Related Groups (MS-DRG) to ICD-10-based MS-DRGs.
How does this process identify any potential updates that might be needed to the GEMs? Will the GEMs be updated to correct any inaccuracies discovered in this process?
Because the process of MS-DRG conversion begins with an initial translation using the ICD-10 to ICD-9-CM GEMs and then uses the ICD-9-CM to ICD-10 GEMs to identify any additional conversion issues, all four GEMs are being tested in the conversion process. Any inaccuracies discovered in the process are immediately noted so that changes can be made to the affected GEMs and included in the next annual update. Currently, the updated GEMs are posted each January to reflect the annual code updates and any corrections or enhancements to the GEMs.
We will continue to update the codes and GEMs on an annual basis. As mentioned in Question 1, the updated GEMs for diagnoses can be accessed in the Downloads Section at http://www.cms.gov/ICD10/12_2010_ICD_ 10_CM.asp, and the updated GEMs for procedures can be found in the Downloads Section at http://www.cms.gov /ICD10/13_2010_ICD10PCS.asp on the CMS website.
What methodology is being used in the MS-DRG ICD-10 conversion?
The goal of MS-DRG ICD-10 conversion is to replicate the current MS-DRG logic. A record coded in ICD-10-CM/PCS and processed according to the converted ICD-10-based MS-DRGs will be assigned to the same MS-DRG as the same record coded in ICD-9-CM and processed according to the current MS-DRG logic. We are accomplishing this goal by translating the lists of ICD-9-CM codes that comprise the MS-DRGs (approximately 500 code lists) to comparable lists of ICD-10-CM/PCS codes without changing the underlying MS-DRG log.i cThis method of replacing lists of ICD-9-CM codes with lists of ICD-10 codes is partially automated using the GEMs.
When do you anticipate that an ICD-10 version of the MS-DRGs will be completed and posted on the CMS website?
A draft ICD-10 version of the MS-DRGs will be completed in October 2009. We will format this ICD-10 version of the MS-DRGs and post it in January 2010 along with the 2010 updates to ICD-10 and the GEMs in the Downloads Section at http://www.cms.gov/ICD10/13_2010_ICD10PCS.asp on the CMS website. We welcome recommendations regarding how this information should be displayed. We believe this exercise will provide useful information to other payers who will be converting their own payment systems. The final ICD-10 version of the MS-DRGs will be subject to formal rulemaking as part of the Inpatient Prospective Payment System.
How soon after a code has been added or deleted will the GEMs be updated to reflect these changes?
We update ICD-9-CM and ICD-10 codes each year. We post updates to the GEMs each January to reflect these annual updates and will continue to update the codes and GEMs on an annual basis. There will be future discussions at the ICD-9-CM Coordination and Maintenance (C&M) Committee meetings as to whether or not we should freeze updates to ICD-9-CM and/
or ICD-10 in order to facilitate planning for I CD-10 implementation. Information about the ICD-9-CM C&M Committee meetings can be found at http://www.cms.gov/
ICD10/16_ICD9CM_Coordination_and_Maintenance _ Committee_Meetings.asp on the CMS website.
Posted by admin on June 26, 2011
Why Do We Need the General Equivalence Mappings?
➤ ICD-10 is much more specific:
* For diagnoses, there are 14,025 ICD-9-CM codes and 68,069 ICD-10-CM codes; and
n* For procedures, there are 3,824 ICD-9-CM codes and 72,589 ICD-10-PCS codes (in the 2009 versions of ICD-9-CM, ICD-10-CM, and ICD-10-PCS).
➤ One ICD-9-CM Diagnosis Code is represented by multiple ICD-10-CM codes:
n 82002 Fracture of midcervical section of femur, closed
— From S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture
— From S72031G Displaced midcervical fracture of right femur, subsequent encounter for closed
fracture with delayed healing
— From S72032A Displaced midcervical fracture of left femur, initial encounter for closed fracture
— From S72032G Displaced midcervical fracture of left femur, subsequent encounter for closed fracture with delayed healing
— And other codes from the GEMs
➤ One ICD-10-CM Diagnosis Code is represented by multiple ICD-9-CM codes:
Posted by admin on June 22, 2011
Is There a One-to-One Match Between ICD-9-CM and ICD-10?
No, there is not a one-to-one match between ICD-9-CM and ICD-10, for which there are a
variety of reasons including:
➤ There are new concepts in ICD-10 that are not present in ICD-9-CM;
➤ For a small number of codes, there is no matching code in the GEMs;
➤ There may be multiple ICD-9-CM codes for a single ICD-10 code; and
➤ There may be multiple ICD-10 codes for a single ICD-9-CM code.
Are There Instances When it is Not Necessary to Use the General Equivalence Mappings?
In the following instances, it may not be necessary to use the GEMs:
➤ When a small number of ICD-9-CM codes are being converted to ICD-10-CM and PCS
codes, it may be quicker, easier, and more accurate to simply look up the codes in an
ICD-10-CM or PCS book; and
➤ When ICD-10 is implemented on October 1, 2013, coders will use coding books or
encoder systems to code rather than using the GEMs.
Posted by admin on May 22, 2011
• Z01.810 Encounter for preprocedural cardiovascular examination
• Z01.811 Encounter for preprocedural respiratory examination
• Z01.812 Encounter for preprocedural laboratory examination
– Blood and urine tests prior to treatment or procedure
• Z01.818 Encounter for other preprocedural examination
– Encounter for preprocedural exam NOS
As I noted previously, many of the V codes you currently report become
similar Z codes in ICD-10 as is true for the preprocedural evaluation
codes. Like ICD-9 – report add’l codes to indicate the reason for surgery
and any pertinent findings
OB by type & trimester
– Z34.00 Encounter for supervision of normal first pregnancy, unspecified
– Z34.01 Encounter for supervision of normal first pregnancy, first trimester
– Z34.02 Encounter for supervision of normal first pregnancy, second
– Z34.03 Encounter for supervision of normal first pregnancy, third trimester
Posted by admin on May 19, 2011
• Z00.110 Health examination for newborn under 8 days old
• Z00.111 Health examination for newborn 8 to 28 days old
• Health checks (routine) for child over 28 days old (29 days and older)
– Z00.121 Encounter for routine child health examination with abnormal findings
– Z00.129 Encounter for routine child health examination without abnormal findings
Note that well child care is based on age:
• under 8 days,
•from 8 to 28 days,
•or 29 days and older.
For the children 29 days and older, you may report routine examinations
with or without abnormal findings.
• Z23 Encounter for immunization
• Z28.3 Underimmunization status
• Z28.0_ Immunization not carried out because
of contraindication (5 choices)
• Z28.2_ Immunization not carried out because
of patient decision for other and unspecified
reason (3 choices)
• Z28.8_ Immunization not carried out for other
reason (3 choices)
• Z01.84 Encounter for antibody response
– Encounter for immunity status testing
Posted by admin on May 15, 2011
What is different…
• Use of a placeholder – x
• Some codes signify initial or subsequent encounter, or
encounter for late effects (sequela in ICD-10)
• Most diagnoses that were V codes in ICD-9 are Z codes in ICD-10
• Identification of trimester when reporting pregnancy
Besides the enormous increase in the number of codes mentioned
previously, some changes to note:
One of the major changes with ICD-10 is the placeholder “x” that is used
in some code categories to allow for later expansion of the category.
Many codes will require selection based on initial, subsequent, or
encounter for late effects (referred to as sequela in ICD-10).
Diagnoses reported with V codes in ICD-9 are mostly reported with Z
codes in ICD-10. V codes in ICD-10 are used to indicate transport
accidents as the external cause of morbidity.
You will find other changes that provide more information such as codes
for pregnancy that include the trimester.
Some are easy…
• Essential (primary) hypertension – I10
• Acute nasopharyngitis (common cold)– J00
• Unspecified lump in breast – N63
• Cough – R05
• Heartburn – R12
Some of the ICD-10 codes are complete with only 3-digits such as the
ones I have provided here.
Posted by admin on May 11, 2011
What is the same…
• Conventions are similar to ICD-9
• Alphabetic index; tables of neoplasms, drugs & chemicals, and external causes; tabular list
• Codes still change each October 1st
• Unspecified codes available when documentation doesn’t support more
Most of the rules for code selection and the basic format of the book are
the same. You still have the alphabetic index with its tables and lists
followed by the tabular index. The codes still change each 10/01 after
2013. You can still report an unspecified code if documentation doesn’t
allow for a more specific code.
Posted by admin on May 9, 2011
A closer look at ICD-10-CM
• All codes start with a letter
• All letters used except U (Be careful not to confuse I and O with 1 and 0)
• 3-digit categories – usually letter and 2 numbers but exceptions: M1a –
• Subcategories expand codes up to 7 alpha-numeric digits
So let’s take a look at the ICD-10 code set. Unlike ICD-9, all ICD-10
codes start with a letter using every letter except U. Be careful when
handwriting codes to make your I and O different from your 1 and 0.
Most of the 3-digit diagnosis code categories are made up of a letter
followed by two numbers but there will be exceptions such as code M1a
that is the category for chronic gout. In order to place this diagnostic
category in the appropriate section of ICD-10, the committee chose to
insert M1a in front of M10, the category for acute gout. The ability to use
alpha characters in any of the digits gives ICD-10 great expandability.
Codes can be up to 7 digits long.
Posted by admin on May 6, 2011
So you need to do some planning to make all the changes that take
effect 01/01/2012 and 10/01/2013. Plenty of time? Not really.
Your software vendor and your clearinghouse will be key resources that
you must plan with and rely on for timely transition. If they fail you, you
will need a back-up plan to get paid. After spending time contacting
vendors, you may have to wait on them to perform system changes.
Early and continuous contact will be important to avoid problems.
You also likely have internal tools that will require an inventory and
thoughtful planning to recreate in ICD-10 or replace. You might find that
some tools are inefficient and the upgrade to ICD-10 will include
changes in processes and tools. If this work is to be performed by your
staff, it will need to be planned around current and ongoing duties.
Don’t expect the delayed implementations that we have seen with past
HIPAA changes such as the NPI. CMS has held meetings and calls for
all entities that will be affected – physicians, hospitals, software
vendors, clearinghouses, and payers. Their message: CMS is
demanding their contractors be ready and they expect everyone else to
be as well. There will be no delays.
Posted by admin on May 4, 2011
The change to the ICD-10 code set is a big one. The codes are
structured differently and as you can see by the 2nd and 3rd bullets on
this page, there will about 5-6 times as many codes in ICD-10. Both ICD
code sets are still being updated each year so we may have more ICD-
10 codes on 10/01/2013 than in 2010. This increased number of codes
reflects the specificity that is available with ICD-10 and also the
complexity of selecting a code.
Many people have asked for a crosswalk between the codes and CMS
has provided a free mapping (forward and backward) but there is not a
one to one correlation. There will be many instances where one ICD-9
code is approximately the same as multiple ICD-10 codes and some
instances where no ICD-9 described a diagnosis represented in ICD-10.
What’s Medical codes should do?
• Updates to electronic systems that transmit and receive eligibility, claims, and other information covered under HIPAA
• Budget for additional software, hardware, and support costs
• All uses of ICD-9 must be redesigned for ICD-10
• Budget for additional staff time, training on ICD-10, and potential cash flow
For your practice, this means any systems that transmit and receive
electronic healthcare transactions must be updated to use the 5010
format and to accommodate the larger ICD-10 data. This will cost you at
least time and labor to coordinate the upgrades, testing, and approvals
for live submission.
Wherever ICD-9 is used in paper or electronic resources, redesign or
replacement will be necessary to use ICD-10. You will have costs to
train physicians and staff on ICD-10 and will likely have a period of
lower productivity for a short time when transitioning to ICD-10.