Looking for an ICD-10 easy button? Well, join the club—because it seems like every way you turn, healthcare professionals are clamoring for an automatic, out-of-the-box solution to the ICD-9-to-ICD-10 translation problem. And plenty of entities have stepped up to satisfy that demand. The problem is, most of their offerings—including automated software systems and plug-and-chug conversion tools like general equivalence mappings (GEMs)—produce less-than-satisfactory results. In fact, relying on those solutions alone could leave you not just unsatisfied, but completely blindsided by the transition to ICD-10. And with ICD-Day—October 1, 2015, that is—rapidly approaching, you can’t afford to waste another second searching for a silver bullet that doesn’t exist.
“But, wait!” you protest. “It does exist! I have seen it with my own eyes!” Well, if you’re referring to the solutions I mentioned above—and I’m assuming you are—then I’m sorry to be the one to disillusion you, but that’s exactly what they are: illusions. And here’s why you shouldn’t be fooled into believing they’ll be your sole saving grace:
1. GEMs cannot reliably produce one-to-one code translations.
As this EHR Intelligence article explains, GEMs were never intended to serve as single-code translation dictionaries. Because of the way they’re structured—in clusters of two to four related codes—GEMs may map one ICD-9 code to several ICD-10 codes and vice-versa. In other words, the majority of the time, GEMs won’t generate a single ICD-10 match for a single ICD-9 code, because “they are an incomplete method of translation,” EHR Intelligence reports. This ICDLogic whitepaper echoes that sentiment: “…the two systems differ so widely that all attempts at translation offer only a series of compromises and subjective choices. This is necessarily so because there is no ‘mirror image’ of one code set in the other.”
So, why do GEMs exist in the first place? EHR Intelligence has an answer for that, too: “GEMs can be used by anyone with a need to convert large batches of data, which will include payers, providers, researchers and informatics professionals, coders, vendors, and anyone with historical ICD-9 data that needs to be usable in the future.” Tasks that are well-suited to the use of GEMs include:
- Generating converted data sets for large databases of ICD-9 codes.
- Aligning data sets for long-term clinical studies that span the transition to ICD-10.
- Analyzing data collected before and after the transition.
- Creating reimbursement mappings to ensure claims containing ICD-10 codes will be paid following the transition.
2. There are no regulations or industry standards governing the creation and use of GEMs.
Although most people associate GEMs with CMS—and thus, assume they’ve been through some type of government quality control review process—the truth is that there are “numerous variations of the ‘national’ GEMs available from a variety of both public and private sources,” ICDLogic explains.
Furthermore, despite numerous efforts—dating all the way back to 2007—to establish national mapping standards for all GEMs, “No industry-wide standards that we are aware of were achieved and today there are many GEMs available from a variety of sources, EHR vendors and payers,” ICDLogic states. “No one really knows whether they are consistent or what the individual organizing principles and assumptions are that each developer used.” Essentially, putting all of your eggs in the GEMs basket would be like eating at a restaurant that doesn’t have to follow any health and safety codes—and that’s a gamble you definitely don’t want to take.
3. There is no automated tool or software that can generate accurate ICD-9-to-ICD-10 conversions 100% of the time.
I get it; it’s 2015, and there’s an automated alternative for pretty much every task. Heck, Google has even created a self-driving car. But when it comes to translating ICD-9 codes into the language of ICD-10, there’s no technology sophisticated enough to do the thinking for you. In fact, as ICDLogic points out, the new code set wouldn’t function the way it’s supposed to without the human decision-making factor: “GEMs are not finite crosswalks because they contain numerous instances of mappings where human intervention and judgment—based on analysis of the clinical documentation—is required to complete many of the links.”
And because most software vendors used GEMs to develop their ICD-10 conversion tools, the same cautionary advice applies to their use as well. Bottom line: while GEMs and code conversion programs can streamline the code selection process by narrowing down your options, you’ll still need to enlist your clinical expertise and critical thinking power to get all the way to the finish line. Here are the code translation steps we recommend following to determine an accurate match:
- Run your ICD-9 code through a conversion tool—like this one—and use the ICD-10 output as your starting point.
- Look up that ICD-10 code in the Tabular List.
- See if there are any variations of the code that offer a higher level of specificity.
- Check the associated category and chapter headings for additional coding instructions.
- If you can, code for the patient’s actual condition (e.g., patellar tendinitis) rather than merely the result of that condition (e.g., knee pain).
- If applicable, list the relevant external cause codes. You can find these codes—which further describe the circumstances of the injury or condition—in chapter 20 of the Tabular List.
All that being said, if you want to use a software to help you streamline your ICD-10 coding process, look for one that uses detailed, defensible electronic documentation as the foundation for code selection—and then empowers you to make the final call on the best code for the job. In other words, your software should get you halfway across the street, but it’s up to you to get all the way to the other side.