ICD 10 Training: Mappings and HIPPA Version 5010

Read this ICD-10 training article and know how GEMs, General Equivalence Mappings; HIPAA version 5010 and MSDRG mappings, the Medicare Severity Diagnosis-Related Group Mappings ICD-10 issues and concerns.

GEMs or General Equivalence Mappings

This is what's going to help us move from ICD-9 to ICD-10 And also, if we have to go back and do some research, et cetera, from ICD-10 to ICD-9. So that mapping goes both ways. It's a crosswalk or mapping between ICD-9 and ICD-10.

There are several organizations that have collaborated to create these GEMs – National Center for Health Statistics, Centers for Medicare and Medicaid, American Health Information Management Association, American Hospital Association and 3M Health Information Systems.

There is a clear one-to-one correspondence from ICD-9 to ICD-10 and that is the exception. If you're familiar with ICD-9 and you saw some of the examples of ICD-10, it's not often that there is going to be an ICD-9 code that matches an ICD-10 exactly.

It may take two or three ICD-9 codes to fully explain an ICD-10 code. So you might have three ICD-9 codes and when you map those over, they might all map to the same ICD-10 code because all the information in those three codes is now combined in the one code.

Forward and backward mapping, you can go both ways. And the code may be linked to more than one alternative. It's not exact.

And there is an example here. Hematuria, 599.7 in ICD-9 can map to the four codes listed on the right side – gross hematuria, benign, essential, microscopic, other microscopic and unspecified.

So it's not always going to be an exact one-to-one. And that's going to be the exception. There is a fact sheet on GEM resources available at a website, “ICD-9 CM/PCS Implementation and General Equivalence Mapping Crosswalks”.

You can actually go out and look at the crosswalks and use them now if you want to. And there is a website listed for that.

Version 5010

If you're familiar with version 4010, this is what we've been using and basically, it's the electronic version of the CMS 1500 claim form.

We might have a paper claim form or a computerized format that we use to submit our claims. It has the demographics for the patient. It has the diagnosis and procedure codes, the charges for those services, the provider, the insurer or the guarantor, et cetera.

All that information that's on the CMS 1500 form converts to the electronic version that is compatible with the payers' systems so that those information can be transferred to their database and they can pay those claims. That version has to be updated to the 5010 in order to accommodate the additional digits in ICD-10.

Over 99% of Medicare A and 96% of Medicare B claims transactions are received electronically as per Medicare guidelines. We submit very few paper claims any more and not only to Medicare and Medicaid but also the large insurers such as Blue Cross, United Healthcare, Aetna. Almost all of them require electronic submission of claims.

Formats currently used must be upgraded from the X12 version or the 4010-A1 to the 5010. It is a HIPAA-mandated format and includes claims, remittance advice or the RA, claim status inquiry response, eligibility inquiry response, your EOBs. Any of those reports that are generated from the claims that we submit will also need to be compatible with that 5010 in order to accommodate those additional digits for ICD-10.

Version 5010 must be implemented no later than January 1st of 2012. Well, we don't have to submit claims in ICD-10 until October 1st of 2013. So that's more than a year and a half in advance of that implementation date.

It's needed to accommodate the seventh digit of ICD-10, promises to decrease staff time needed to verify eligibility, claim denials and appeals, et cetera. And once you have the correct format, of course, you're going to have your fewer medical coding claim rejections.

MSDRG mappings

These are for those of you who code in-patient, the Medicare Severity Diagnosis-Related Groups. ICD-9 or ICD-10, the same patient is assigned to the same MSDRG.

So basically, the DRGs are not going to change at this time. It's not expected to. But the codes that are grouped into that diagnosis-related group will look different.

And somebody is working on, okay, these particular ICD-9 codes mapped to a certain DRG. They are now going to have to translate that into ICD-10 codes that are equivalent.

Not everything is going to be equivalent but they are certainly going to be using those mappings to change the ICD-9 codes to the ICD-10 diagnosis codes that then are grouped into the diagnosis-related group for your in-patient coding and claims submission and billing.

It will be clinically equivalent. Definitions manual has a familiar look and feel. And the GEMs produce 95% of the MDC-6 mapping without any need for review.

So basically, if you have an automated system right now that groups your ICD-9 codes into your DRGs, the ICD-10 is pretty much going to do the same thing. So for right now, at this time, there's not going to be a tremendous change that you're going to see to your DRG groupings.

Several websites listed there that you can do some further research on the Medicare Severity Diagnosis-Related Groups, the conversion project, the executive report from AHIMA and converting MSDRG 26.0 to ICD-10 CM and ICD-10 PCS. So if you're involved in that, you might want to go out and look at some of those resources.

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