The time is finally here. After delays and much deliberation between government and physicians, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This goes into effect tomorrow, October 1, 2015.
ICD-10 stands for the International Classification of Diseases, version 10. It is a coding system that attaches a number for every disease of trauma known to the medical world. According to the World Health Organization, ICD is “the standard diagnostic tool for epidemiology, health management, and clinical purposes. It is used to monitor the incidence and prevalence of diseases, providing a picture of the general health situation of countries.” In the U.S., the ICD has been adapted for billing. While work on ICD-10 started in 1983, HHS used ICD-9 until 2013 and was subsequently delayed twice by Congress. ICD-11 only exists in draft form and is not expected until 2020 or 2025.
As we previously wrote, the U.S. has lagged behind other countries in updating to ICD-10, but the process is by no means a quick fix. The number of procedural and diagnostic codes is estimated to increase from about 17,000 unique codes in ICD-9 to over 140,000 unique codes in ICD-10. A procedure like an angioplasty, for example, will shift from having 1 code to having 854 possible codes, according to reporting done by MedPage Today.
Physicians are concerned the new system will cause additional administrative burdens with new documentation requirements that, if incorrectly applied, could result in denied claims (See Kevin MD). In fact, an August survey by Navicure/Porter Research shows that an "overwhelming majority (94%) of participants" anticipate an immediate increase in their denial rate, with 56% of respondents citing ICD-10's impact on revenue and cash flow as their top concern. Practice administrators and billing managers comprised the majority of survey respondents (58%), followed by practice executives (14%) and billers and coders (14%). While survey respondents represent a range of specialties and sizes, two-thirds (67%) are from organizations with one to 10 providers.
Some flexibility issued by CMS
In July, CMS announced that it would provide greater flexibility during the transition to ICD-10 billing codes. Specifically, while diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation date, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. Starting October 1, 2015, however, CMS will require a valid ICD-10 code.
CMS addressed its interpretation of “family of codes” in a recent document, saying the codes are the same as the ICD-10 three-character category. CMS writes: “Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.”
“Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid."
CMS remains fully committed to ICD-10
“As we work to modernize our nation’s health care infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” said Andy Slavitt, Acting Administrator of CMS this July.
“With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.”
In a recent Q&A document, CMS outlined answers to several common ICD-10 questions. The agency writes that it “understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.”
Politico reports CMS contingency plans
According to Politico, CMS has plans in place depending on the scenarios that could take place during the transition to ICD-10. Politico writes the five specific CMS contingency scenarios include: (1) CMS’s systems are working fine, but providers have an inability to submit any codes; (2) Providers are submitting ICD-10 codes, but incorrect ones; (3) CMS’s systems are not working correctly; (4) There is an additional delay to ICD-10; and/or (5) There are problems with submitting claims unrelated to ICD-10. If Medicare systems are not working properly, CMS will hold claims while issues are resolved. If providers are having issues, the agency will remind providers of their options including submitting paper claims. You can read more at Politico’s website on the contingency plans (subscription required).
Some helpful tips
Hire a certified coder if you do not have one on staff already. Other recommendations include scaling back on the number of patient visits booked in October, giving physicians extra time to learn and incorporate ICD-10. Additionally, experts suggest a focused approach to learning the codes to help avoid becoming overwhelmed. Take the top 100 ICD-9 codes and become familiar with their ICD-10 version. Finally, thorough documentation will be a critical step to make a smooth transition into ICD-10 coding.