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Perils of Using GEMs as Crosswalks for ICD-10 Transition

CMS advised that GEMs should not be used to code patient encounters due to numerous documented shortcomings, assumptions, exceptions and deficiencies as a coding translation tool for coding.

By John Pitsikoulis of Berkeley Research Group

- During the ICD-10 preparation phase, many vendors, clinicians, and IT administrators converted their current I-9 environment with an approach that included using the general equivalence mappings (or a version of the GEMs) as the key mechanism for preparing their ICD-10 coding and billing tools. One of the challenges with the conversion to the ICD-10 code set was the initiative to duplicate the ICD-9 code set in the EHR system with the new expanded ICD-10 code set.

ICD-9 to ICD-10 crosswalks could prove dangerous

Since there was no standard approach for preparing the industry for the new ICD-10 environment, healthcare entities adopted various approaches and methodologies to accomplish this goal.

The GEMs have become the gold standard approach for many payers, providers, and software vendors for the transitions from ICD-9 to ICD-10. It is understandable how one would use the GEMs — if they wanted general equivalence code translations. However for functions such as coding and billing, this is not a logical solution as the GEMs intent was to generally match an I-9 code to the ICD-10 code.

Since the development of the GEMs, the Centers for Medicare & Medicaid Services (CMS) has stood firm in their advisement that GEMs are not crosswalks, rather reference mappings to help the user navigate the complexity of translating meaning from one code set to others. CMS advised that GEMs should not be used to code patient encounters due to numerous documented shortcomings, assumptions, exceptions and deficiencies as a coding translation tool for coding.  

Unfortunately, many practice managers and hospital administrators will be in for a rude awakening with ICD-10 outcomes. As a result of the very small percentage of one-to-one code matches between ICD-9-CM and ICD-10, EHRs, code search tools, and data conversions tools that relied on the GEMs as a crosswalk made the grave mistake of vastly underestimating the complexities of ICD-10 coding.

EHR technology and coding tools intended to assist the physicians with code selections are many times configured in a manner that facilitates the selection of an incorrect code. The physician EHR user may only be accessing a subset of codes converted with the GEMs, thereby resulting in the assignment of unspecified or other coders converted as a GEMs default selection. Remember, the GEMs “crosswalk” only contains a very small percentage of one to one code equivalents; resulting in a system configuration that is in many instances less accurate than your ICD-9 system.

As we all know, ICD-10 transition is not just a coding change; it is also a clinical documentation specificity issue. Many organizations provided clinical documentation specificity education, which was a necessity for preparing for ICD-10 compliance. However, physicians are not coders with many having received only minimal training on the new coding tools and less likely education on ICD-10 coding guidelines and conventions.

An EHR system with an incorrectly configured coding workflow combined with the clinical documentation requirements significantly increases the revenue and compliance risk that the code selected by the physician is not supported by the clinical documentation in the EHR system.

As with any major regulatory changes, opportunities to improve performance, mitigate risks and compliance with the regulatory changes become apparent through a detailed analysis. Knowing the risks associated with the misuse of the GEMs, starting with EHR coding tools and structure configuration is an optimal approach for providing the physicians with improved workflow.

More importantly, enhancements to the EHR coding and billing functions, regardless of the EHR platform, will provide the physicians who perform their own coding an accurate and compliant process. Physician billing process workflow simplification and compliance must be a priority to provide the physician with a decreased administrative burden so that they can dedicate time to their top priority, the patient.

John Pitsikoulis is a Managing Director at Berkeley Research Group with more than 30 years of consulting experience. He has provided advisory services to clients related to complex business problems including EMR optimization, operational process improvement, coding and clinical documentation.

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