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AAOS Now

Published 12/1/2014
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Sarah Wiskerchen, MBA, CPC

Mapping Your Way to ICD-10 Implementation Success

As orthopaedic surgeons and their practice teams ready themselves for the implementation of ICD-10, a team-based transition action plan is essential. One step in making the transition is known as “mapping.” Mapping describes the process of comparing the codes currently used in ICD-9 to those that will be used in ICD-10 for the same condition or injury.

Mapping helps to illustrate the differences in documentation requirements between ICD-10 and ICD-9. It enables physicians to identify whether they are meeting the increased documentation elements required to report ICD-10 codes at the highest levels of specificity. If they aren’t, there is time to identify and correct deficiencies, to begin using the more granular diagnosis code descriptions, and to receive feedback and make improvements.

Because ICD-10 uses a completely new structure (3 to 7 characters) and varied character patterns, orthopaedic groups will initially use code mapping as a transition tool to learn the new system. Eventually, however, as they become more comfortable coding in ICD-10, they can stop using the ICD-9 code set as a reference point.

To begin your mapping activities, identify the practice’s top 25 or 30 ICD-9 codes using the billing system. Then identify the ICD-10 equivalents. Because ICD-10 has many more codes than ICD-9, a one-to-one mapping is not always possible. For example, ICD-9 has about 17 codes for a femur fracture while ICD-10 has more than 2,600 codes for a femur fracture. Practices need to fully implement the documentation requirements (code descriptions) defined by ICD-10 before Oct. 1, 2015.

GEMS mapping
The most basic form of mapping was developed by the Centers for Medicare & Medicaid Services (CMS) and is called GEMs, or General Equivalency Mappings. Using them, practices can identify the ICD-10 code that resembles the same condition or injury in ICD-9. Although the GEMs offered by CMS are free, they may not provide the best mapping.

For example, Table 1 shows some mapping examples drawn from a “real-life” frequency report, representing the levels of specificity that many groups use. Close review of these examples shows that the GEMs ICD-10 alternative for each ICD-9 code is an unspecified code option for the condition or injury.

However, this may be a clue that ICD-10 has multiple options for that code, especially if the word “unspecified” appears before the anatomic site. The ICD-9 code for rotator cuff (726.10) has several options for multiple forms of tear in ICD-10. The same is true with respect to fracture type (ICD-9 code 813.42). Laterality options are not displayed in any of these GEMs mapping results, but the need for designating laterality is indicated by the use of “unspecified” before the anatomic site.

Furthermore, GEMs mapping provides the code that would apply for an initial encounter (see Table 1, ICD-9 codes 813.42 and 836.0), designated by the 7th character “A.” However, other 7th character options could apply. (See “When 7 Is Not a Lucky Number,” AAOS Now, November 2014.)

These examples show that GEMs provides a starting place, but its mapping results are not fully specific. Using codes resulting from a GEMs mapping for claim submission would not be appropriate when more specific codes could be reported. Although using GEMs is good as a learning tool, it is not useful as a long-term solution in practice.

This is a critical point for practices to consider when electronic health records and practice management software vendors offer to provide cross-walk tools. Vendors who say that their mapping is based on GEMs should be asked how the system will help the practice assign the most detailed level of specificity because GEMs won’t be enough.

Other mapping options
Once a practice has identified the GEMs crosswalk codes, it can take two approaches. Option 1 is to invest in a more detailed mapping tool or software program. The American Medical Association publication ICD-10-CM Mappings is one option. The 2015 release of the AAOS Orthopaedic Code-X program also will have more detailed mappings and cross references to CPT. This will greatly improve the speed and efficiency of searching for ICD-10 codes.

Option 2 is for the practice to develop its own mapping table using the ICD-10 book. Key steps include the following:

  • Generate a CPT frequency list for each provider, and identify their top 15 to 25 ICD-9 codes.
  • Use the CMS GEMs file to identify the ICD-10 GEMs crosswalk code(s) for each ICD-9 code on the list. The GEMs data is stored in an ASCII file that can be imported into any spreadsheet program, but the codes do not include the decimal point found in the ICD-9 and ICD-10 books. For example, ICD-9 code 719.56 will appear as the number 71956, and ICD-10 code M25.669 will appear as M25669. In addition, there are no GEMs crosswalk options for ICD-9 codes that are designated as needing to be coded to a higher level (often designated with a red plus sign). If the frequency report includes these types of unspecified codes, claims denials are probable.
  • Locate the GEMs ICD-10 crosswalk code(s) in the tabular section of the ICD-10 book, or look them up in the AAOS Code-X. When using Code-X, go to the “ICD-10 Search By Keyword” screen, and enter the base characters (eg, M25.66, M66.2, M75.10) in the Code field. The system will produce a list of both the unlisted and more specific codes that apply.
  • Study the details of the code’s category and create a list of the description parameters that apply. For this stage, it’s not necessary to write down every ICD-10 code in detail; the focus should be on the descriptor elements that lead to greater code specificity. The point is to generate a template that will prompt the physician to document each element necessary to lead to the correct code.

Table 2 displays more detailed options that could apply to the four ICD-9 code examples from Table 1. For ICD-9 code 719.56, laterality is the only element of detail that adds new code options: M25.661 Stiffness of right knee, NEC, and M25.662, Stiffness of left knee, NEC.

For ICD-9 code 726.10, in addition to laterality, the ICD-10 code is selected based on the type of rotator cuff rupture or tendon type. For ICD-9 code 813.42, selection options include laterality, fracture site, alignment, Salter Harris classification, and the encounter stage. Options for ICD-9 code 836.0 are laterality, tear type, and encounter stage.

The ICD-10 examples that include the hyphen character indicate that additional alpha or numeric characters are required to correlate with the specific details described (laterality, site, alignment, encounter).

When performing this type of mapping analysis, groups may find that they’ve been using unspecified ICD-9 codes when more specific codes exist. Learning the details of ICD-10 will help to prevent groups from carrying this coding bad habit with them during the implementation transition. It is important for each member of the practice who uses diagnosis codes to actually look at ICD-10 to get a feel of what the code descriptors look like and the associated documentation requirements.

When to start
The time to start mapping is now. Completing this exercise will help physicians and staff to understand how documentation details become essential to code specificity in ICD-10. For more information, attend one of the AAOS ICD-10 education workshops, kicking off in Dallas in January 2015.

Sarah Wiskerchen, MBA, CPC, is a senior consultant with KarenZupko & Associates, Inc. She is an instructor for the 2015 AAOS CPT and ICD-10 coding workshops.

New ICD-10 Education Program Coming
“ICD-10 by the Numbers” is a 10-program series cosponsored by the AAOS and KarenZupko & Associates. The AAOS Practice Management and Coding, Coverage, and Reimbursement Committees are overseeing the program.

The first program in the series—“Introduction: ICD-10-CM Architecture & Structure, Osteoarthritis, Joint Pain”—walks the learner through the basics of the ICD-10 code structure and demonstrates how to correctly apply ICD-10 codes to clinical cases. It also introduces a set of specific orthopaedic diagnosis groups—osteoarthritis and joint pain—to demonstrate how to apply the new coding concepts.

The 10 modules can serve as a training program to educate those responsible for diagnostic coding on how to correctly apply ICD-10 coding principles. They also demonstrate the importance of anatomic specificity in patient documentation for accurate coding of the most common orthopaedic diagnoses in each orthopaedic specialty area. Look for details on this new educational program in January.