ICD-10: by the numbers
An important change to the way you code for reimbursement is coming. take steps now to avoid a traumatic transition.
By Daniel Sosnoski
There’s no need to panic about coming changes to patient coding protocols, but be sure you have a plan in place to help you through the changeover. Because coding is at the heart of reimbursement, accuracy will be more important than ever before.
Keep in mind that this isn’t a case of a new bureaucracy being imposed on you for mysterious reasons. Rather, the U.S. has been lagging behind the rest of the world and today we’re the last country still employing the ninth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-9). It’s the official list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
Despite annual updates, ICD-9 has fallen further behind the times and is now showing its age. Revisions are unable to keep pace with the need for more specific codes that reflect changes in technology and advancements in medical science.
You may have noticed that ICD-9 codes are either vague or unable to adequately describe certain nonacute conditions, especially in the areas of physical therapy, home care, and nontraditional care settings. Because of its numbering scheme, some ICD-9 codes are effectively “full,” rending more precision impossible.
As a result, either previous codes get combined, or a new section is found under a different category. The result is a constantly shifting landscape that is problematic and confusing for coders who increasingly have to memorize exceptions and workarounds.
Given these realities, the World Health Organization (WHO) developed ICD-10 to address the aforementioned shortcomings of ICD-9. The new coding scheme was purposefully designed to be easy to modify and grow with changes in the healthcare arena. It was first implemented in Australia in 1998, and Canada followed suit in 2000. Other countries rapidly adopted the standard over the next decade.
ICD-10-CM (for diagnosis coding) is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the U.S. It is based on ICD-10 as developed by WHO. The ICD-10-PCS (for procedure coding) is maintained by CMS.1 (Note: ICD-10- PCS only applies to inpatient settings and won’t apply to most chiropractors.)
Missing the target
Every country that adhered to ICD-9 has by now switched to ICD-10, leaving the U.S. in the lagging position of being the last to adopt the new system. The Centers for Medicare and Medicaid Services (CMS) indicated that “all HIPAA-covered entities” were to be in compliance with EDI Vers. 5010 (electronic healthcare record standard — a prerequisite to ICD-10) by Jan. 1, 2012.
As often happens with major rule changes, deadlines get pushed back. So it was not surprising that in February 2012, the U.S. Department of Health and Human Services (HHS) announced their intent to delay the adoption of ICD-10 beyond the previously established Oct. 1, 2013 deadline.2 The new compliance deadline suggested by HHS is Oct. 1, 2014.
While other countries are almost all dealing with a single-payer system, switching in the U.S. will be more difficult as there are hundreds if not thousands of payers that all have to coordinate for a successful transition.
Even though a new target date for ICD-10 implementation has not been set, it’s a good idea to familiarize yourself with the general outlines of the new system so you understand the basic process you’ll be following to convert to the new standard.
Will ICD-10 apply to me?
It almost certainly will. It will apply to diagnosis and procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just those who submit to CMS. If you are covered by HIPAA and transmit electronic claims, you must also switch to Vers. 5010. CPT coding for outpatient procedures will not be affected.3
The shape of things to come
As a chiropractor, you won’t need most of the 155,000 expanded codes in the new system. After all, you don’t need many of the current 16,000 codes available in ICD-9 now. That’s the good news. The catch is that there won’t be a straight code-for-code substitution in every case.
Also, HIPAA privacy policies signed by all patients will need to be revised and patients will have to sign all new forms. Your office manager will be affected by any policy or procedure tied to diagnosis codes. Your PQRS or disease management protocols will be affected.
What’s more, your insurance billing and coding staff will need more education and knowledge about anatomy and medical terminology. And you as a chiropractor will have a larger documentation responsibility.
You’ll find ICD-10 to be more rich and precise for coding, and if you master the system you’ll likely improve your claims accuracy. The system will enable better quality monitoring and statistical analysis. If you code and practice well, you’ll be rewarded in a number of ways — eventually. Expect the first few years following implementation of ICD-10 to be turbulent and some time will be needed to collect data.
- Some elements of the new scheme are the same and the function of coding isn’t changing.
- ICD-10 allows greater tracking of services, so accuracy will be essential.
- There will be significant changes to the way you document and file.
- Keeping a positive attitude will make a successful transition easier.
How hard will it be?
The American Hospital Association and the American Health Information Management Association conducted a field test for ICD-10-CM in the summer of 2003.4 Based on comments and feedback from participants, ICD-10 was adjusted to reflect the realities of applying it in practice.
According to the feedback, the clinical descriptions of ICD-10-CM codes were judged superior to those of ICD-9-CM by about 72 percent of the participants.4 Only about 10 percent said they weren’t sure if the system was an improvement or not.
Key points: Asked how many hours of ICD-10-CM training they thought they would need prior to implementation:
- 60 percent of participants said they would need 16 hours or less.
- About 24 percent felt they would need between 17 and 24 hours of training.
The game plan
There won’t be a one-size-fits-all solution available for making the transition, since each practice is unique. The difficulty may in part depend on the kind of patients you see and conditions you treat.
You’ll want to develop a transition strategy that includes:
- an assessment of the impact on your practice
- a detailed timeline
- a budget
Before the next announced date of implementation, it would be prudent for you to check with your billing service and practice management software vendor. What are their plans for compliance? If you handle your own billing and IT, you’ll have to involve your entire team in transitioning to Vers. 5010 and ICD-10. This is required by June 30, 2012.
The following steps should be considered a suggestion, and you’ll likely modify it in ways to better suit your individual circumstances. The main point is to be organized and approach things in a systematic way.
Establish HIPAA 5010 compliance
The Vers. 5010 transaction sets are text files formatted to transmit claim information for evaluation. In implementing transaction set 5010, you’ll test transactions with vendors, clearinghouses, HMOs, and similar. Ensure that you can send and receive 5010 files as preparation for ICD-10.
The prior HIPAA Vers. 4010 trans- action sets cannot transmit in the ICD-10-CM alphanumeric coding scheme. CMS has educational materials on its website to help you transition. Visit CMS.gov, select “regulations and guidance,” then “HIPAA administrative simplification.” Select “versions 5010 & D.0.”
Learn the ICD-10-CM codes
Whereas ICD-9 employs three- to five- digit codes, ICD-10 codes use three to seven digits.5 You may be worried because where ICD-9-CM had about 14,000 diagnosis codes, ICD-10-CM has almost five times as many (68,000).
The larger number of codes allows for more detailed diagnoses and specification of laterality.
For example: M21.271 would be the appropriate code for “flexion deformity, right ankle and toes.”
M21 indicates “other joint disorders,” 2 indicates “flexion deformity,”7 indicates “ankle or toes,” and 1 indicates the right side of the body. The seventh and final position of an ICD-10 code is a qualifier, and if this example was for an initial encounter, you would add “A” to it, giving the final seven-digit code: M21.271A.
Determine the impact
You can be sure that your practice will not be working with all 68,000 codes. Chances are you’ll be focused on only a few sections.
For example: Section E00 to E90 applies to endocrine, nutritional, and metabolic diseases; section G00 to G99 applies to diseases of the nervous system; and section M00 to M99 applies to diseases of the musculoskeletal system and connective tissue. You may work with other sections but for most DCs, these sections will be most frequently applied.
Once you are familiar with looking up ICD-10 codes in tables, determine which ICD-9 codes are the most common in your practice. This will help you determine where you need to focus your efforts in learning the codes you’ll be working with the most.
A great tool has been developed for you to use at this stage: The General Equivalence Mappings (GEMs). These are dual lists of codes that try to cross- walk the ICD-9 versions to their ICD-10 counterparts. They were developed jointly by CMS and CDC to help you make the transition.
When you cross-walk your codes to the new versions, you’ll see the changes in coding structure, documentation requirements, and ascertain where you need training the most.
- GEMs are tools, not necessarily a one-to-one cross-walk.
- A diagnosis or procedure code in ICD-9 may not have an exact correspondent in ICD-10.
- Think of GEMs as being two-way dictionaries — you’ll need to work back and forth to find the connections you need.
Design your transition plan
It is highly recommended that you appoint a “team leader” to coordinate and organize your transition plan among your staff and external partners affected.6 This may be you, your senior coding expert on staff, or someone else you deem best suited.
When the team leader has located the ICD-10 codes that will be used the most in your billing and documentation and has a sense of the scale of the effort needed for transition, he or she should create a plan to guide the process.
The team leader should post benchmarks and assign timelines for implementing them. The action plan should have deadlines, and name the key individuals responsible for meeting those targets. Add some extra time in the schedule to allow for unforeseen challenges.
Also, establish a budget. Your expenses may include hardware and software upgrades in addition to staff training. You should anticipate some financial turbulence in the short term following the transition, and the reports from field testers suggest that the increased effort and time needed to comply with ICD-10 may reduce your weekly patient average. In fact, some experts are recommending practices set aside up to six months of cushion in case of reimbursement issues.
Adhere to your timeline
You received a break when the government deadline of Oct. 1, 2013 was postponed. This allows you to focus on HIPAA 5010. Most software vendors have ICD-10 on their radar and are either revising their electronic health records (EHR) and practice management systems to be compliant, or have plans to do so.
If you are still in the market for an EHR system, make sure your chosen product has cross-walk capabilities (matching ICD-9 codes to ICD-10 versions) as well as the ability to use ICD-10 codes natively. If you are going with certified EHR qualified for CMS incentive payments, start establishing meaningful use.
It isn’t too early to assign a team leader (if you are delegating that task), and sketch out a blueprint for your transition plan. Any preparations you make now will reduce your burden of compliance later. You can consider holding off on ICD-10 coding training for the present. The American Association of Professional Coders says that training taken too soon may need to be repeated. Wait for the announced deadline of Oct. 1, 2014, to be confirmed and then plan training based on that date.
Perform due diligence and establish your priorities. Take preparatory steps now to sketch out the shape of your transition plan and with a committed team working with you, your journey to ICD-10 will be a successful one.
1CMS Fact Sheet. HHS Modifies HIPAA Code Sets (ICD-10) and Electronic Transactions Standards. E-pub available at: www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3407
2U.S. Department of Health and Human Services. HHS delay of ICD-10 implementation. www.hhs.gov/news/press/2012pres/02/20120216a.html
3Center for Medicare and Medicaid Services. CMS ICD-10 Introduction Fact Sheet. www.cms.gov/ICD10/Downloads/ICD10IntroFactSheet20100409.pdf (accessed 4/2/2012).
4American Health Information Management Association. ICD-10-CM Field Testing Project Summary Report. www.ahima.org/downloads/pdfs/resources/FinalStudy.pdf
5Centers for Disease Control. ICD-10-CM Official Guidelines for Coding and Reporting 2012. www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf
6Maguire N. How to Survive the ICD-10-CM/5010 Transition. 2012 Webinar; www.kareo.com.
ICD-10 timeline (extended)
|Healthcare industry moves to coded data|
|1979||World Health Organization (WHO) adopts ICD-9 and U.S. adopts ICD-9-CM|
|1983||Inpatient prospective payment system—DRG links code data with reimbursement|
|1988||Medicare Catastrophic Coverage Act requires physicians to report conditions using ICD-9-CM|
|World moves to updated classification system|
|1994||WHO adopts ICD-10|
|1995||U.S. draft of ICD-10-CM made available|
|1996||HIPAA (Heath Insurance Portability and Accountability Act) enacted: new code set adoption process falls under legislative control|
|Legislative steps to ICD system conversion|
|2003||National Committee for Vital and Health Statistics (NCVHS) recommends the secretary of Health and Human Services adopt ICD-10-CM and ICD-10-PCS under HIPAA standards|
|2008||Notice of proposed rulemaking (NPRM) published in the Federal Register with a proposed implementation date of October 1, 2011|
|2009||HHS publishes final rule in the Federal Register, adopting ICD-10-CM and ICD-10-PCS effective October 1, 2013|
|2012||Version 5010 electronic billing process and format compliance on January 1, 2012 (except for small health plans; January 1, 2013); CMS enforcement discretion is in place until June 30, 2012|
|2013||ICD-10-CM/PCS compliance effective October 1, 2013, for all HIPAA-covered entities|
|2013||HHS announces postponement of October 1, 2013 deadline; no new compliance date yet specified|