What You Should Know About ICD-10-CM Codes

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Author(s): 
Barbara Aung, DPM

As the deadline to convert to ICD-10-CM codes approaches, don’t get caught unprepared for the transition. This author delineates important differences between the ICD-10 and ICD-9 codes, and offers pointers on what you need to know to update your coding in order to receive full reimbursement in the future.

As part of the final rules of HIPAA Administrative Simplification to Medical Date Code Set Standards, ICD-10-CM was initially adopted in 2009 with a mandatory compliance date of October 1, 2013. Health and Human Services Secretary Kathleen Sebelius recently announced the postponement of the date of implementation for ICD-10 to October 1, 2014. We can all take a deep breath now.

   Still, given the magnitude of the forthcoming changes, it is highly advisable to start working now to get your practice ready to meet the actual deadline in 2014.

   Why are ICD-10-CM diagnosis codes so important to practitioners? Having 68,000 codes now available, we will or should be able to tell a more complete and accurate story regarding a patient’s specific encounter. Many of the entities we deal with, such as the Centers for Medicare and Medicaid Services (CMS) and insurance payers, noted that ICD-9-CM codes lack specificity and detail in the claims we submit currently. The ICD-9 codes fail to give a full picture of the specific encounter and we often repeat diagnoses on follow-up examinations. Additionally, we may not be selecting diagnosis codes to the highest specificity and/or fully support medical necessity for the encounter we are billing for. Also, ICD-9 is running out of codes to keep up with newly developed advances in technologies and new procedures as only 13,000 codes are available.

   All payers are seeking more precise quality data as we move into the “pay for performance” arena in healthcare. How does this relate to new devices and treatment modalities? While most companies with new devices claim that their products are superior in comparison to their competitor’s products, I have not encountered many, if any, products that have statistical data to provide cost to benefit/outcome evidence. This makes it difficult for payers to determine if they should continue to cover the item or procedure, and compare the benefits of different technologies. Finally, the United States cannot compare its data and outcomes with other countries to determine how it is doing in providing quality healthcare services when we are using a different system from the rest of the world.

   The belief is that ICD-10 will reflect each patient encounter more accurately, describing underlying causes of disease and explaining complications of care provided. All of this goes toward providing supporting documentation for medical necessity, coverage for payment, statistical tracking of the practice and the practitioner, the type of treatment or procedures performed, and tracking the incidence of disease. Payers would accordingly be able to match the ICD-10 codes to the procedure(s) and products billed, and thus be able to “audit” services provided for easier bill verification.

   This should not scare us. We generally are already doing the things we need to do to document the services we are providing. We now have the opportunity to improve our documentation process. General coding guidelines require providers to use appropriate codes to identify diagnoses, symptoms, conditions, problems, complaints or reasons for the specific encounter. We use signs and symptoms when we have yet to determine or confirm a definitive diagnosis. With the numbers of codes available with the ICD-10 codes, we may not need to use codes for signs and symptoms as often as more specific codes are likely to be available.

   So why wait until January 2014 to start getting ready to implement ICD-10? We must start looking at how we are documenting and the processes within our office so that we can refine and develop an implementation plan.

How Are The Codes Changing?

Let us first look at the structure of our current ICD-9 coding in comparison to the new ICD-10-CM structure.

ICD-9-CM
XXX.XX

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