ICD 10

ICD – 9 is 30 years old and has become outdated. ICD – 10 would be replacing ICD – 9 code sets on 1st October 2015. Every entity covered by the HIPAA should get transitioned to ICD 10 and impact would be felt by almost everyone in healthcare industry in US.

  • ICD 10 CM (Clinical Modification) & ICD 10 PCS (Procedural Coding System) – Will go live from 1st October 2015
  • ICD 10 will help in reporting severity of disease and be more accurate (for instance – services performed on LT or RT / unspecified part of the body)
  • ICD 10 will have 68,000 odd diagnosis codes in comparison to 13,000 odd diagnosis codes in ICD 9
  • Diagnosis code will be 7 alpha numeric code in ICD 10 compared to 3 to 5 in ICD 9
  • 1st digit will be alpha, 2nd digit will be numeric, 3 to 7 could be alpha numeric
  • ICD 10 PCS – Will be for Hospital Inpatient billing alone. All others will use CPT & HCPCS codes even after 1st October 2015
  • ICD 9 had 17 chapters and 2 supplemental chapters in comparison to 21 chapters in ICD 10 with no supplemental chapters
  • ICD 10 – E & V diagnosis codes will have different meaning
  • Any claim with date of service or date of discharge till/prior to 09/30/2015 would need to be billed in ICD 9 format
  • Claims with date of service from 10/01/2015 should be billed in ICD 10
  • Physician inpatient claims starting end of September 2015 and discharge in October 2015 might have to be a split claim. For instance, patient getting admitted on 9/28/2015 and will be discharged on 10/02/2015. Date of service 09/28/2015 till 09/30/2015 should be submitted in ICD 9 format and date of service 10/01/2015 till 10/02/2015 should be submitted in ICD 10 format
  • New HCFA claim form will be used to submit claims in ICD 10 format effective 4/1/2014.
  • CMS does not develop ICD 10 code books however they only provide guides. ICD 10 books are available in the market now
  • 5010 was implemented to process ICD 10 transactions. Framework for ICD 10 is already in effect with 5010 is in place now
Comparison between ICD 9 & ICD 10

Diagnosis Code Comparison

Characteristic ICD-9-CM
(Vol 1 & 2)
ICD-10-CM
Field length 3-5 characters 3-7 characters
Available codes Approximately 13,000 Approximately 68,000
Code composition
(numeric or alphabetical)
Digit 1 = alpha or numeric
Digit 2-5 = numeric
Digit 1 = alpha
Digit 2 = numeric
Digit 3-7 = alpha or numeric
Overall details embedded within codes Ambiguous Very specific (allows description of comorbidities, manifestations, etiology/causation, complications, detailed anatomic location, sequelae, degree of functional impairment, biologic and chemical agents, phase/stage, lymph node involvement, lateralization and localization, procedure or implant related, age related, or joint involvement).
Laterality Does not identify right Vs left identifies right Vs left
Sample code 813.15, open fracture of head of radius S52123C, Displaced fracture of head of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC.

 

Sample ICD 10 implementation timeline for Large Physician Practices

Sample Implementation Timeline
Action Steps
Action to take immediately

  • Inform core group and senior management of upcoming changes (1 month)
  • Create a governance structure, such as project management team, interdisciplinary steering committee, executive sponsor, and/or ICD-10 coordination manager (1 month)
  • Perform an impact assessment and identify potential changes to existing work flow and business processes (6 months)
    • a) Collect information from each department on current use of ICD -9 and the number of staff members who need ICD-10 resources and training; staff training will mostly likely involve billing and other financial personnel, coding staff, clinicians, management, and IT staffs.
    • b) Evaluate the effects of ICD-10 on other planned or ongoing projects (eg. Version 5010 transition, HER adoption and Meaningful use)
  • Determine business and technically implementation strategy (1 month)
  • Develop and complete implementation plan, including a communications plan (3 months)
  • Estimate and secure budget, including all costs associated with implementation such as software and software license costs, hardware procurement, and staff training costs (2 months).
Business Processes Affected by ICD – 10 transition
  • Referrals
  • Authorization/precertification
  • Patient practice intake
  • Patient clinic encounters
  • Patient hospital encounters
  • Physician orders
  • Medical records
  • Analytics
  • Contracting
  • Research participation
  • Public health reporting
  • Risk management

 

Advantages of ICD – 10
  • Improve patient care. The increased level of detail within ICD-10 is designed to improve the ability to measure quality, safety and efficacy of care, which should ultimately lead to improved patient care.
  • Improve research. For example, ICD-10 is likely to open new opportunities in injury research and trauma services evaluation, since the code set more accurately classifies the nature of injuries and correlates them with cause, treatment, and outcome. The new code set will also allow the U.S. to conduct comparative effectiveness research with other countries that already use ICD-10.
  • Lend insight to the setting of health policy. With higher quality data analytics afforded by ICD-10, policy leaders will be empowered to better informed policy decisions.
  • Facilitate improved public health reporting and tracking. The increased level of detail will enable agencies to track public health risks and trends in greater detail.
  • Improve clinical, financial and administrative performance. The quality data afforded by ICD-10 can reveal insights into patterns of care and more. These insights enable administrators to make more informed decisions and achieve positive clinical and financial outcomes.
  • Allow for monitoring of resource utilization. The ICD-10 codes will allow administrators to track the amount of time spent on procedures, enabling them to better allocate resources.
  • Increase the accuracy of payment and reduce risk that claims will be rejected for incorrect coding. It is expected that the greater specificity within ICD-10 will mean fewer claim denials and more timely payment for providers in the long run.
  • Reduce the need for payers to request copies of medical records. The greater specificity within ICD-10 codes should give payers more insight, reducing the need for payers to request medical records and thereby reducing costs.
  • Make room for new procedures and techniques. The ability to code innovative procedures is limited by ICD-9, which has been exhausted and has no more room for new codes. ICD-10 will expand this capability to accommodate advancing medicine.
Cost of Non-Action
    • a. Limited code space in ICD 9
    • b. Delayed payments/reimbursement
    • c. Increased fragmentation
Challenges in ICD 10 conversion with Auto & Work Comp Payers

Auto and Work Comp payers are considered non-covered entities which mean they may or may not recognize ICD 10 code sets. Providers might have to submit claims for date of service 10/01/2015 for Auto and Work Comp payers in ICD 9 format. It would be up to the providers to confirm with Auto & Work Comp payers if they need to submit the claims in ICD 10 or 9 format. Unfortunately, CMS does not have a list of Auto & Work Comp Payers if they are converting to ICD 10 or not.

Any system should be set up to bill below appropriately –

  • HIPAA covered entity (Date of Service till 09/30/2015) – ICD 9 code set
  • HIPAA covered entity (Date of Service from 10/01/2015) – ICD 10 code set
  • Auto & Work Comp (Date of Service from 10/01/2015) – ICD 10 code set for payers agreed to move to ICD 10
  • Auto & Work Comp (Date of Service from 10/01/2015) – ICD 9 code set for payers that disagreed to move to ICD 10