August 5, 2015 – The United States is coming up on the mandatory adoption of ICD-10, which goes into effect on October 1, 2015. As most people in the health care industry know, the shift from ICD-9 to ICD-10 has been delayed several times. The original implementation date was October 1, 2011, which was then pushed back to October 1, 2013, then October 1, 2014, and now October 1, 2015.

This time, however, it looks like all health care billing will have to utilize ICD-10 billing codes. According to the Centers for Medicare & Medicaid Services (CMS), ICD-10 will affect everyone covered by the Health Insurance Portability Accountability Act (HIPAA) — not just those submitting Medicare or Medicaid claims.

Barring something unusual, the Medicare claims processing systems will no longer be able to accept ICD-9 codes for dates of services after September 30, 2015. They also won’t be able to accept claims for both ICD-9 and ICD-10 codes.

The change affects medical diagnoses and inpatient procedures, but doesn’t affect coding for outpatient procedures.

ICD-9 versus ICD-10

Although the change has been in the works for some time, it has been decades since there have been modifications to the International Classification of Diseases (or ICD) that’s used to standardize codes for medical conditions and procedures.

The American Medical Association (AMA) notes: “The medical codes America uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms.”

ICD-9-CM diagnosis codes had three to five digits, with the first digit being alpha (E or V) or numeric. V codes were for Factors Influencing Health Status and Contact with Health Services. E codes were for External Causes of Injury and Poisoning. There is no indication of laterality, no placeholder characters and there are about 14,000 codes.

ICD-10-CM diagnosis codes run up to seven digits, include laterality, and allow “X” placeholders. There are about 69,000 codes, which will allow more specificity. There are also extensive severity parameters.

Other changes include grouping injuries by anatomical site as opposed to type of injury, and E and V codes have been incorporated into the main classification system rather than being separated into supplementary classifications. Moreover, critical medical information has been updated, the system has been restructured and some diseases have been reclassified to reflect current medical knowledge.

An Overview of ICD-10

ICD-10 diagnosis codes have between three and seven characters. Three-character codes are included in ICD- 10-CM as the heading of a category of codes. That category will be subdivided by the fourth, fifth and sixth characters, which provide greater detail concerning etiology, anatomical site and severity. The seventh character is only used in certain chapters to give information regarding the characteristic of the medical encounter.

Examples include:

• I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris.
• S72.044G Non-displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing.

Examples of laterality, are:

• C50.511 Malignant neoplasm of lower-outer quadrant of right female breast.
• C50.512 Malignant neoplasm of lower-outer quadrant of left female breast.

According to the CMS: “A dummy placeholder of ‘X’ is used with certain codes to allow for future expansion and/or to fill out empty characters when a code contains fewer than six characters and a seventh character applies. When a placeholder character applies, it must be used in order for the code to be considered valid.”

For example:

• H40.11X2 Primary open-angle glaucoma, moderate stage.

The 2015 diagnosis codes can be found in the ICD-10-CM Index to Diseases and Injuries http://cdn.roadto10.org/wp-uploads/2014/08/2015-ICD-10-CM-Index-to-Diseases-and-Injuries.pdf in alphabetical order, and in the ICD-10-CM Tabular List of Diseases and Injuries http://cdn.roadto10.org/wpuploads/2014/08/2015-ICD-10-CM-Tabular-List-of-Diseases-and-Injuries.pdf .

Example Showing the Old and New Codes

Here is an example of the differences shown between ICD-9 and ICD-10 with a femur fracture.

• ICD-9: 821.11
Open fracture of Shaft of Femur
All codes for femur fracture: 16

• ICD-10: S72.351C
Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
All codes for femur fracture: 1530

Action Plan

The deadline for this changeover is barreling down on parties involved in health care billing and those who utilize diagnostic codes. At some level, that means almost all parties involved in health care in the United States. The CMS has developed an interactive guide to help you develop an action plan. It’s called the “Road to 10: The Small Physician Practice’s Route to ICD-10” and can be accessed here. http://www.roadto10.org

For medical practices, the website asks users to pick a specialty, provide the practice size, and supply information about electronic health records, practice management systems and billing services. It also asks questions about payers and at what stage of planning the practice is at in ICD-10 implementation. Then, it creates a detailed action plan and calendar for getting ready.

Plan and Test

Obviously, a change this big is going to be disruptive. Hopefully, most health care providers have been working on the transition since it was first announced in 2009, especially when the 2013 deadline looked like it was going through.

Make sure you complete internal and external testing prior to October 1, 2015. The CMS states, “Practices should plan to test claims, eligibility verification, quality reporting, and other transactions and processes that involve ICD-10 codes from beginning to end.”

Staff members should take courses, especially those involved in coding and billing. Affiliated hospital systems, medical societies, payers, clearinghouses and associated professional organizations may offer online and instructor-led courses and training regimens.

The bad news? The American Health Information Management Association (AHIMA) recommends that training should start no later than six to nine months before the deadline. If you haven’t started, do it now.

Medicare Assistance

In case things do go wrong, the CMS and AMA announced some relief on July 6, 2015. Medicare claims, for the first year of ICD-10 use, won’t be denied or audited based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct family of codes in the new code set. According to the CMS, “If Medicare contractors cannot process claims due to problems with ICD-10, CMS will authorize advance payments to physicians.” In addition, an ICD-10 ombudsman hired by the CMS will assist in sorting out problems via the agency’s “Coordination Center.”

If you have questions about the coding change, or need help implementing it, contact your medical practice management or health care adviser.

Proposed Legislation: But Some Industry Leaders Not in Favor

After multiple delays, ICD-10 implementation is set for October 1, 2015. But, will there be further delays?

In July 2015, Representatives Marsha Blackburn (R-Tenn.) and Tom Price (R-Ga.) introduced a House bill, the Code-FLEX Act, which would provide a safe harbor for the transition. It would allow health care providers to submit claims in both ICD-9 and ICD-10 for six months after the October 1 deadline. This is the third bill proposed to either repeal ICD-10 or provide a transition period. And, some medical industry experts say that doing both ICD-9 and ICD-10 simultaneously would be difficult or impossible.

Another bill introduced by Rep. Diane Black (R-Tenn.) called the Transitioning Effectively Now Act (ICD-TEN Act), would require complete transition testing by Health and Human Services (HHS) and an 18-month transition period.

“Neither Congress nor the provider community support kicking the can down the road and supporting another delay,” Black wrote in a letter to fellow legislators, “but we must ensure the transition does not unfairly cause burdens and risks to our providers, especially those serving Medicare patients.”

The American Health Information Management Association (AHIMA), however, doesn’t support the proposed laws, expressing concerns that a transition period would make fraud more possible, and that some providers would just use the time to delay learning the new codes.

We’ll keep you updated, but health care providers shouldn’t delay making plans in the hopes of another delay or transition period.

The Healthcare Services Group specializes in providing accounting, tax, payroll & employee benefits, practice management, consulting, compliance and other services to physicians, clinics, hospitals and healthcare systems, ambulatory surgery centers, dentists, orthodontists and other healthcare providers.

If you wonder how the information in these articles might affect you or your healthcare practice, please contact me at (843) 577-5843 or by email at nfields@websterrogers.com.