The healthcare industry usually follows General Equivalence Mappings (GEMS) reimbursement maps, as a primary crosswalk map for undertaking financial neutrality analysis. GEMS reimbursement maps, provide a one-to-one code map, and include clinically non-equivalent mappings in its fold. Appx 30% of all one-to-one maps are not clinically appropriate, thereby questioning the neutrality analysis performed using these maps. Also, to guard against reimbursement variations post compliance, you need to undertake financial neutrality testing to assess these 1 to 1 maps for data-sets pertaining to the patient population they cater to.

The second most important but hidden impact is on the reports using ICD-9 codes generated by providers. All of these codes need to map to corresponding ICD-10 code maps (one-to-many) for diagnosis reports following the migration. Unfortunately, here too the GEMS maps come up short. Appx 30-40% of the GEMS indicated code maps need to be enhanced to map additional ICD-10 codes, so as to cover all possible clinical conditions. Else, providers risk generating inaccurate reports which may affect critical inputs for budget and financial planning, regulatory compliance, and operations management.

For example, if a hospital wants to analyze data pertaining to patients with mitral valve disease, they would probably be using the ICD9 code 394.9 (Other and unspecified mitral valve diseases). This code maps to only one ICD-10 code I05.8 (Other rheumatic mitral valve diseases) as per the GEMS map. However, another ICD-10 code I05.9 (Rheumatic mitral valve disease, unspecified) is also clinically equivalent to the ICD-9 code 394.9.

Some examples (Year on Year/ Quarter on Quarter) where Custom Reporting Maps can be used:

How it Works?