GEMS Files
Corrie Alvarez, CPC, CPC-I,
CEDC
1
Objectives
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Why move to ICD-10-CM?
Review ICD-10 Final Rule
Understand GEMS files
Illustrate how the files work
Review practical examples
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Why ICD-10-CM?
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ICD-9-CM is 30 years old
Advances in Medicine and Technology
Need for more accurate data
No room for expansion
3
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
4
2
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
6
ICD-10-CM
• 2010
• 69,000+
6
3
Format and Structure
7
7
ICD-10 CM Format
X
X
X
Category
8
X X X
Etiology, Anatomical site, Severity
X
Extension
8
4
Code Set Comparison:
Diagnosis Codes
•
ICD-9-CM Diagnosis
g
Codes
•
ICD-10-CM Diagnosis
g
Codes
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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
•
•
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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
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9
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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
5
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
6
Who Will Use Them?
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Health Plans
Providers
Medical Researchers
Medical Software Vendors
13
GEMS
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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
7
How Will GEMS Be Used?
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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
8
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
9
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
ØBH17EZ Insertion
endotracheal device
into trachea via
natural or artificial
opening
ØBH18EZ 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
1
None
1
23
Procedure Code Mapping
ICD-9-CM Source 
≈
ICD-10-PCS Target
51.23 Laparoscopic
cholecystecomy
≈
ØFT4ZZ 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
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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
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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
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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
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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
1
5
ICD-9 CM Code Source
6
1
(Fill )Ch
(Filler)Character
t is
i left
l ft blank
bl k
7
7
ICD-10CM Code Target
14
1
(Filler)Character is left blank
15
1
16
1
17
1
18
1
19
1
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
1
7
ICD-10 PCS Code Source-all seven characters used
8
9
1
5
14
15
1
1
16
1
17
1
18
1
19
1
(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
6
0
1211
583
458
36
38
19
Reimbursement Mapping File Layout
Position
Length
Contents
1
8
I-10 Code (3 to 7 characters) left justified in 8 character field. Last character in field is left
blank.
9
1
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
6
First I-9 code (2 to 5 characters) left justified in a 6-character field. Last character is left blank.
16
6
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
6
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
6
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
6
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.Ø33ADisplaced
fracture of lateral end
of unspecified
clavicle, initial
encounter for closed
fracture
S42.Ø36ANondisplac
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
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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
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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
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• 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
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Thank You!
• Questions?
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