On October 1, the nation will adopt the new ICD-10 diagnosis code set. ICD-10 is the 10th edition of The International Statistical Classification of Diseases and Related Health Problems, published by the World Health Organization (WHO). ICD-10 codes are “a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.” Effective through the American Recovery and Reinvestment Act, ICD-10 applies to all HIPAA covered entities—not just those who submit claims to Medicare/Medicaid—including all third party payers. Even if you don’t accept Medicare or Medicaid, you will be required to process all claims with the date of service of October 1, 2015 onward, with an ICD-10 code and for all claims with a date of service prior to October 1, 2015 with an ICD-9 code. Invoices and claims submitted with ICD-9 codes after October 1, 2015 will be rejected. Note that this update does not affect CPT or HCPCS codes.
ICD-9 is Outdated
While many providers believe the implementation of ICD-10 is unnecessary and burdensome, other physicians and industry stakeholders believe that the ICD-9 code sets have become too outdated and are no longer workable for treatment, reporting, and payment processes today. ICD-9 has been used widely in the U.S. since 1978. The World Health Organization (WHO) endorsed ICD-10 in 1990 and many countries have adopted versions of it.
Another driver for replacing ICD-9 is the increased specificity of ICD-10. It is believed the more specific data will provide better information for identifying diagnosis trends, public health needs, epidemic outbreaks and bioterrorism events. The more precise codes also have the potential benefit for fewer rejected claims, improved benchmarking data, improved quality and care management, and improved public health reporting.
We’ve Run Out of Codes in ICD-9
During the years of maintaining and expanding the codes within sections, the more complex body systems have run out of codes. The lack of available codes within the proper section has resulted in new codes being assigned to sections of other body systems. For example, new cardiac disease codes may be assigned to the section for diseases of the eye. The rearranging of codes makes finding the correct code more complicated.
If you are not ready, your claims will not be paid. The current ICD-9 system has not kept up with the changes in healthcare and medicine. There are new conditions and treatments, and ICD-10 will improve the reporting of these by including much more detail on the condition. ICD-10 improves classifying inpatient hospital procedures by providing better data through quality and safety measures, efficacy of care, and payment systems and claims processing. It also improves such items as:
• Health policy
• Strategic planning
• Design of healthcare delivery
• Detection of fraud and abuse
• Monitoring of resource utilization
Currently in ICD-9, the code is made up of three to five characters. There are 14,000 current codes, with 4,000 of them being Procedure Codes. The first digit can be an alpha or numeric character and there is no use of an “X” character.
An ICD-10 code is three to seven characters. There are 68,000 codes Clinical Modification codes (CM codes) and 87,000 Procedure Coding System (PCS) codes (used for inpatient procedure coding only). The first digit is always an alpha character. There is an “X” character used in the fifth position as a placeholder in certain six-character codes to allow for expansion at a later date. The codes identify the location laterality—such as left, right or bilateral. The codes have been reclassified to reflect current medical knowledge, and there are combination codes for certain conditions with commonly associated symptoms and manifestations. The codes include clinical concepts that do not exist in ICD-9, such as under-dosing, blood type and blood alcohol level. There has been an expansion of codes that address such things as:
• Substance abuse
• Post-op complications
21 new chapters were created to replace the outdated sections, such as:
• E00‐E89 Endocrine, Nutritional & Metabolic Diseases
• J00‐J99 Diseases of the Respiratory System
• K00‐K94 Diseases of the Digestive System
• M00‐M99 Diseases of the Musculoskeletal System
• S00‐T88 Injury, Poisoning & Certain Other Consequences
Often the seventh character is used to define the type of the encounter, such as:
• A = Initial Encounter
• D = Subsequent Encounter
• S = Sequellae
With fracture codes, the seventh character identifies if the fracture is open or closed for an initial encounter or if a subsequent encounter is for routine healing, delayed healing, nonunion, malunion, or sequellae.
Coding plays a large role in every area of the healthcare continuum. Certified coders are needed, but not in DME, since DME is not clinical. Nonetheless, we must have the proper codes for reimbursement and audit issues.
DME providers may have problems come October 1 because vendor or payer systems may not be ready and staff confirming codes may not have sufficient understanding of anatomy and physiology to choose the correct code. We could experience increased delayed in claims processing or an increase in rejections and denials, which will slow cash flow. The unintentional improper use of new codes could result in future audit issues.
The Center for Medicare and Medicaid Services (CMS) is the agency that is responsible for oversight of the implementation and compliance with the ICD-10 regulation. Additional resources are available on the CMS website: cms.gov/ICD10.