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:
|
Area |
Indicative Quality Measure |
Diagnosis Used |
|---|---|---|
| Quality Measure | Acute Myocardial infarction core measure set | AMI (ICD-10) – I23.8 |
| Stroke (STK) core measure set | Cerebellar stroke syndrome (ICD-10) G46.4 | |
| Brain stem stroke syndrome (ICD-10) G 46.3 | ||
| Physician Groups & Medical Home | Avoidance of anti-biotic treatment in adults with acute bronchitis (AAB) | Acute bronchitis(ICD 10) – J20.0 |
| Diabetes Mellitus: Hemoglobin A1c poor control | Type 1 diabetes mellitus (ICD-10) E10 | |
| Type 2 diabetes mellitus (ICD-10) E11 | ||
| Drug or chemical induced diabetes mellitus (ICD-10) E09 | ||
| Strategic Reports | OR room utilization by case type | Diagnosis based data segregated by procedure type and specialty |
| Operational, financial analysis report | Capacity and utilization | Average length of stay, acute care, case mix adjusted |
| Trend and Predictive analytics reporting | Readmission rate | Using ICD codes for calculating the possible readmission of patients based on certain diagnosis |
| HEDIS reporting | Comprehensive diabetes care | Type 1 diabetes mellitus (ICD-10) E10 |
| Type 2 diabetes mellitus (ICD-10) E11 |
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Kunal Sawant
Dr Kunalsen Sawant is medical physician with more than a decade of experience working with...
Thanks for sharing the valuable post. ICD-10-CM was designed to offer significant advantages over ICD-9-CM. These changes should result in major improvements in both the quality and uses of data for various healthcare settings. In 1994, WHO developed the tenth revision of the ICD system. The purpose of the revision was to expand the content, purpose, and scope of the system and to include ambulatory care services, increase clinical detail, capture risk factors in primary care, include emergent diseases, and group diagnoses for epidemiological purposes.