Clinical Limitations of ICD-10 General Equivalencies Mappings

Many healthcare payers and providers are utilizing or planning to utilize General Equivalencies Mappings or GEM’s as a primary means of addressing ICD-10 compliance – at least during the period immediately before and after the transition date; and primarily for reimbursement purposes. It's important that organizations understand that GEM’s aren't intended to be “clinically correct” - at least without significant review, discussion and modification.

Four Limitations to Consider:

Organizations planning to use GEM’s may understand the stated and implied limitations of GEM usage.  And there are some clinical considerations these organizations should also be aware of:

1.    Use of the “Initial Encounter” and “Subsequent Encounter” classifier may not always be clear.

2.    An “exact match” may not always be “truly exact” – but rather an “approximate match.”

3.    Codes marked with a “Combination Indicator” are not always consistent.

4.    Some mappings are not anatomically equivalent.

What Clinical Impact Might GEM's Have?

1.   Episodes of care and global periods may not reflect reality.

2.   GEM’s may exclude or include codes in error contrary to your true intent.

3.   The intent of medical policies, business rules and/or clinical analysis & related selection criteria may not reflect original intent.

4.   Reporting of data aggregated using ICD-9 and ICD-10 coded data converted using GEM’s may not be truly comparable.

While GEM’s and casually constructed, purpose-built maps based on GEM’s can be a means to short-term compliance – particularly for purpose of reimbursement, GEM’s are not without risk and can actually present a good argument for native redefinition of diagnoses mappings.