ICD-10 Launch for October 1, 2015

Only 5 months to go until the launch of ICD-10!  There is nothing to indicate the federal government will again delay this implementation.  ICD-10 (diagnostic codes) does not affect CPT (procedural) coding for outpatient procedures and physician services.

Here are some of the changes in regard to the diagnosis codes in ICD-10:

  • ICD-10 has gone from 17 chapters to 21 chapters.  In ICD-9, there were V-codes and E-codes that were not classified as “chapters.”  That accounts for 2 of the 4 new chapters.  The other 2 are the result of diseases of the eye and ear each being promoted out of the nervous system chapter.  There are also some codes that have been reclassified into more appropriate categories based on current medical knowledge.

  • Documentation has been touted as one of the biggest challenges with ICD-10, requiring more specificity in order to obtain the most accurate code to describe the patient’s condition.   The goal of documentation is to give an accurate depiction of the symptoms that lead to diagnosis, and the treatment course chosen to most effectively care for the patient.  The physician is offered a greater number of combination codes in the groups of quality measures in the Physician Quality Reporting System (PQRS) to more succinctly report the more common etiologic and manifestation relationships.
  • There is a significant change in the diabetes mellitus codes.  In ICD-9, there was only the 250 category.  With ICD-10, there are 5 categories, but the most significant change is the combination codes that were created.  These added combination codes actuallyreduce the number of codes to report.  Rather than using 2 codes to describe a single condition, the diabetes combination codes describe both the etiology and the manifestation all in one code. E.g. a type 2 diabetic retinopathy with macular degeneration under ICD-9 would have taken 3 codes to capture every detail of this condition; in ICD-10, it only takes 1 code.  This is true for each of the other 3 categories of diabetes mellitus.  There is going to be a longer list of possible codes in the diabetes group, going from 54 to 92 under ICD-10.  No longer will there be queries asking if the diabetes is controlled or uncontrolled.  This classification is removed from ICD-10.  However, if the terms “inadequately controlled,” “out of control,” or “poorly controlled” are used in documentation, coders will be guided by the ICD-10 index to use the type of diabetes with hyperglycemia.
  • Asthma is another reportable diagnosis in the PQRS Measures Group.  The number of reportable diagnoses for asthma has increased by 4 under the ICD-10 with the terms “mild intermittent,” “mild persistent,” “moderate persistent,” and “severe persistent.”

DOCUMENTATION FOCUS AREAS:       

CMS and the American Health Information Management Association provided the following list for provider documentation improvement:

  • Disease type
  • Disease acuity
  • Disease stage
  • Site specificity
  • Laterality
  • Missing combination code detail
  • Changes in timeframes associated with familiar codes.

By improving documentation in these areas, a clear picture of the patient is provided throughout the care continuum for more accurate coding.

CODING EFFECTIVELY AND EFFICIENTLY: 

It is important to ensure your coding procedures are optimized to minimize denials, avoid under coding and knowing how to appeal rejected claims.

If you have a denial rate that is higher than 5%, you have a problem according to the Medical Group Management Association.  The most common reasons for denials are:

  • missing information (such as prior authorization or dates of service),
  • insufficient documentation,
  • coding errors related to the place of service,
  • missing modifiers and late submissions (each payer has its own deadline for filing claims), and
  • confusion over primary and secondary insurance, particularly with Medicare.

Medicare may deny claims for services deemed “not medically necessary,” either because the diagnosis does not align with the service or because it’s covered only at certain frequencies or the proper authorizations have not occurred.

Identify someone in the office as the “coding Czar” who can review denials and find the common trend.  Always appeal in writing and follow the provider manual guidelines.  Submit supporting documentation.  It will usually pay off.

Proper and efficient coding is the single best defense against rising costs and shrinking reimbursement.

For more information on ICD-10 and Road to 10, an online resource built with input from providers, use the following website: http://www.cms.gov/Medicare/Coding/ICD10/index.html

Click here to see more online ICD-10 resources, including:

  • PowerPoint by the AR Dept of Human Services: ICD-10 Preparation & Implementation
  • CMS web link
  • AACP ICD-10 Code Translator
  • Americaln Medical Assocation ICD-10 Article