Are you ready for ICD-10?
By Bradley Reiner
TAFP partners with Bradley Reiner to provide family physician members with practice management assistance.
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I thought that ICD-10 might never happen. They have been talking about it for years. We have heard other countries are using it and how much better it is for the patients and the doctors. It sounds good, but how much work is involved in implementing a system like ICD-10? Considering we’ve been using ICD-9 for as long as we can remember, we find ourselves wondering if a huge transition like this is even possible. They were on the cusp of implementation in October 2014 and at the last moment decided to postpone for another year. Oct. 1, 2015 is fast approaching and everyone is scrambling, making sure they’re prepared. I was still thinking this implementation would get delayed again. Then something happened. Last year a delay to ICD-10 came on the heels of a delay in the SGR that thwarted a reduction in Medicare payments to doctors. This year the SGR was fixed and under new legislation there was no delay in ICD-10, thus ending any speculation that the new system would be postponed further.
While there was no delay, The Centers for Medicare and Medicaid Services and the American Medical Association announced a grace period in early July that will ease the transition this fall. Essentially, for the first year that ICD-10 is in place, Medicare claims coded incorrectly will still be accepted, as long as the code used is from the appropriate family of ICD-10 codes. To understand more about this grace period, go to http://blogs.aafp.org/fpm/gettingpaid/entry/cms_ama_offer_additional_guidance. Note that all claims dated Oct. 1, 2015 or later must still be submitted with valid ICD-10 codes; ICD-9 codes will no longer be accepted.
A little education on ICD-10
The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced with ICD-10 code sets on Oct. 1, 2015. ICD-10 consists of two parts:
- ICD-10-CM, diagnosis coding for use in all U.S. health care settings.
- ICD-10-PCS, inpatient procedure coding for use in U.S. hospital settings.
ICD-10 will affect everyone, not just Medicare and Medicaid. The addition of ICD-10 includes over 68,000 codes as opposed to the 13,000 in ICD-9. This is a significant change for coding services. Choosing an ICD-9 code for abdominal pain, 789.0, is fairly simple. With ICD-10 there may be 11 or more codes to choose from for abdominal pain. It will be your job to decide which one is the most appropriate choice.
Claims for services provided on or after the compliance date should be submitted with ICD-10 diagnosis codes. Claims for services provided prior to the compliance date should be submitted with ICD-9 diagnosis codes. This will be confusing for the months surrounding the transition, even with the year grace period.
The code set has been expanded from five positions (first one alphanumeric, others numeric) to seven positions. The codes use alphanumeric characters in all positions, not just the first position as in ICD-9.
Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of any or all of the fourth, fifth, and sixth characters. Digits four through six provide greater detail of etiology, anatomical site, and severity. A code using only the first three digits is to be used only if it is not further subdivided.
A code is invalid if it has not been coded to the full number of characters required. This does not mean that all ICD-10 codes must have seven characters. The seventh character is only used in certain chapters to provide data about the characteristic of the encounter. Examples of where the seventh character may be used include injuries and fractures.
The new code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code. The terminology has been modernized and has been made consistent throughout the code set. There are codes that are a combination of diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition.
The ICD-10-CM code set enables reporting of laterality (right vs. left designations), reflecting the importance of which side of the body or limb (e.g., left arm, left kidney, left eye) is the subject of the evaluation. It also restructures reporting of obstetric diagnoses. In ICD-9-CM, the patient is classified by diagnosis in relation to the episode of care. In ICD-10-CM, the patient is classified by diagnosis in relation to the patient’s trimester of pregnancy.
Other important changes to note in ICD-10-CM:
- Importance of anatomy: Injuries are grouped by anatomical site rather than by type of injury.
- Incorporation of E and V codes: The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM.
- New definitions: In some instances, new code definitions are provided reflecting modern medical practice (e.g., definition of acute myocardial infarction is now four weeks rather than eight weeks).
- Restructuring and reorganization: Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM.
- Reclassification: Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge.
By now you’re probably wondering how you can get ready for this transition.
- It is important to ensure that all payer and all technology systems are prepared for the transition. Contact your top payers and ask them how they are preparing for ICD-10. Some payers, like Medicare, are doing testing with practices to ensure that claims go through cleanly. This is something every practice should complete to ensure everything works on the day of implementation. Contact Medicare to participate.
- Start transitioning your ICD-9 codes into ICD-10 codes. You can do this by determining the top diagnosis codes that you utilize. Remember, there will likely be a number of ICD-10 codes for each ICD-9 code billed. The ICD-10 codes can be found at www.cms.gov.
- After you have determined the ICD-10 codes you plan on utilizing most frequently, contact your vendor and ensure these codes are in their data base and available to use on Oct. 1. This is a critical step so there will be no delay in claim billing or payment. It would also be wise to ensure the payers will be accepting the codes you have identified.
- Train your physicians and staff on the new code sets and how everyone will be impacted by the use of these diagnoses. Retrain monthly to ensure everyone is up to speed on how they will be utilized by October.
- CMS has an excellent site for planning and meeting the goals for ICD-10. Review the site they created at www.roadto10.org. They include a step-by-step action plan for implementing ICD-10 into your practice. This is an excellent way to establish your systems and develop guidelines for success.
It is important to remember that the new ICD-10 code sets are not to be feared. With some preparation and education, your practice can be prepared for this landmark change to medical coding and billing.
Bradley Reiner, formerly with Texas Medical Association, has been owner of Reiner Consulting and Associates for 15 years. He is TAFP’s endorsed consultant and is a billing and coding auditor for the Texas Medical Board. He can be reached at (512) 858-1570 or firstname.lastname@example.org. See more about the services Reiner provides to TAFP members at www.tafp.org/practice-resources/reiner.