ICD-10-CM Crosswalks in the primary care setting: assessing reliability of the GEMs and reimbursement mappings.

Turer RW, Zuckowsky TD, Causey HJ, Rosenbloom ST
J Am Med Inform Assoc. 2015 22 (2): 417-25

PMID: 25665703 · DOI:10.1093/jamia/ocu028

OBJECTIVE - The general equivalence mappings (GEMs) and reimbursement mappings (RMs) facilitate translation between ICD-9-CM and ICD-10-CM. This study compared prospectively dual-encoded diagnoses assigned by professional coders with the GEMs/RMs in a clinical setting.

MATERIALS AND METHODS - Professional coders manually encoded diagnoses from 100 primary care notes into both ICD-9-CM and ICD-10-CM. The investigators evaluated whether manual mappings were reproducible using the GEMs/RMs. Reproducible mappings with one ICD-9-CM and one ICD-10-CM code ("one-to-one") were classified as exact or approximate using GEMs flags. Mismatches were characterized manually.

RESULTS - Manual encodings were reproducible from the forward GEMs, backward GEMs, and RMs in 85.2%, 90.4%, and 88.1% of diagnoses, respectively. For one-to-one, reproducible mappings, 61% (forward) and 63% (backward) were approximate mappings compared to 85% and 95% in the GEMs as a whole. Mismatches between manual and GEMs encodings were due to differences in coder interpretation (11%-13%), subtle hierarchical differences (52%-55%), or unknown reasons (32%-35%).

DISCUSSION - This study highlights inconsistencies between manual encoding and using the GEMs/RMs. The number of approximate mappings in our population compared to all one-to-one GEMs entries supports the notion that statistics describing the GEMs as a whole might not represent the most important mappings for each organization. The mismatch characteristics highlight the subtle differences between manual encoding and using the GEMs/RMs.

CONCLUSION - These results support the need for organizations to assess the GEMs and RMs in their own environment to avoid changes in reimbursement and longitudinal statistics.

© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

MeSH Terms (6)

Clinical Coding Humans Insurance, Health, Reimbursement International Classification of Diseases Primary Health Care Reproducibility of Results

Connections (1)

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