Countdown to ICD-10: Is Your Practice Ready?

By now, you have heard about the looming switch to ICD-10-CM diagnosis codes. The date established by CMS for converting to the new codes is October 1, 2014. While that date seems far in the future, it is not too early to start learning about ICD-10 and planning for the transition. The sooner you begin, the more comfortable you will be with the now-unfamiliar diagnosis codes when the switch occurs.

Regulatory Background

The final rule adopting ICD-10 diagnosis codes was published in the Federal Register on January 16, 2009. There are actually two code sets, ICD-10-CM for diagnosis coding and ICD-10-PCS for inpatient procedure coding. Note that ICD-10-PCS applies only to hospital inpatient procedures. The Current Procedural Terminology (CPT) codes will continue to be used for outpatient procedures.

The Department of Health and Human Services issued the rule as a modification to the HIPAA code sets standards. Thus, any health care provider covered by HIPAA is required to use the ICD-10 codes for electronic claims and other HIPAA standard transactions. Originally, October 1, 2013, was designated as the he compliance date for the transition to ICD-10. A later rule delayed the effective date to October 1, 2014, in order to allow covered entities time to prepare and to facilitate more thorough testing. CMS has signaled that there will be no further delays.

The switch to ICD-10-CM is being driven by the limitations of the current ICD-9-CM code set, which is more than 30 years old. ICD-9 contains approximately 16,000 procedure and diagnosis codes but the structure limits the number of new codes that can be added. Additionally, it was never designed to provide the level of detail that is needed for modern health care and health information technology.

In comparison, ICD-10-CM contains 68,000 diagnosis codes and provide much more detailed information within the codes. The transition will allow the United States to align itself with other nations of the world, which have already adopted the more advanced ICD-10 code set.

How are ICD-10 Codes Different?

ICD-10 diagnosis codes are alpha-numeric and contain three to seven digits, compared to the three to five digits of ICD-9 codes. Because of the increased level of detail that ICD-10 brings, there is not a one-to-one relationship of ICD-9 to ICD-10. For any one ICD-9 diagnosis, there could be several ICD-10 codes providing more granularity. Take for example, the ICD-9 diagnosis:

724.4 Thoracic or Lumbosacral Neuritis or Radiculitis unspecified.

When mapping this diagnosis to ICD-10, the following equivalences are found:

M54.14 Radiculopathy, thoracic region; or M54.15 Radiculopathy, thoracolumbar region; or M54.16 Radiculopathy, lumbar region: or M54.17 Radiculopathy, lumbosacral region.

As you can see, a more precise diagnosis is possible with the newer code set. On the other hand, some ICD-9 diagnosis codes convert directly to a single ICD-10 code: ICD-9-CM: 723.1 Cervicalgia equals ICD-10-CM: M54.2 Cervicalgia.

Making the Switch: The Date Matters

As mentioned previously, the compliance date for ICD-10 is October 1, 2014, and all payers, clearinghouses and providers will switch to the new codes on the same date. Dates of service prior to the transition must be billed using ICD-9 and services performed on October 1, 2014, and later must be billed using ICD-10. A complication is that services cannot be billed using ICD-10 until October 1, 2014. In other words, health care providers cannot start using ICD-10 codes early. They must wait until the cut-over date to begin using the new codes. Claims including dates of service from before the transition date and which include ICD-9 diagnosis codes will be denied.

A common misunderstanding is that ICD-10 codes will be required by Medicare only and that if providers do not bill Medicare, they are exempt from using ICD-10. Every insurance company (with noted exceptions) will deny claims for dates of service on October 1, 2014, and later that contain ICD-9 diagnosis codes. Some payers, such as workers' compensation and auto insurance companies, are considered non-covered entities under HIPAA. These payers may continue to accept ICD-9 codes. However, because ICD-9 will no longer be maintained after the transition and due to the intrinsic benefits of the updated codes, non-covered entities will be encouraged to also adopt ICD-10.

[pb]HIPAA also offers an exclusion for "small providers" who have fewer than 10 full-time employees and who do not perform electronic transactions. These providers who continue to file claims on paper are technically exempt from using ICD-10. But, from a practical point of view, insurance companies must convert to ICD-10 for electronic transactions, so they are very unlikely to continue to accept paper claims with ICD-9 diagnosis codes. It is probable that the paper CMS-1500 claim form will be modified to support ICD-10 codes sometime prior to the transition date. A revised claim form has been proposed but CMS has not yet approved the changes.

How to Prepare

You can take steps now to prepare for ICD-10 compliance:

• First, create a plan for the transition, including a budget for education and training, software upgrades, printing and other related costs. Take into account all materials in your office that reference ICD-9 codes, such as super bills and other forms. Communicate the plan to your staff, and assign individual duties and deadlines.
• Determine what educational resources such as are available to you to become familiar with the new diagnosis coding system. Recognize that it will take time to learn the new codes.
• Talk with software vendors, clearinghouses and third-party billing services to determine their plans for supporting ICD-10. Now is the time to find out whether or not your practice management software will be upgradeable for ICD-10.

How Software Can Help

As daunting as it seems, transitioning to the new codes will be easier than you think, when aided by technology. CMS has provided General Equivalence Mapping (GEM) tools to assist in moving from ICD-9 to ICD-10. Software developers are building the GEMs into their products so that providers can more easily convert patients' diagnosis codes. It will be important for doctors to obtain software for ICD-10 several months in advance of the compliance date so that they can begin to convert their patients to ICD-10 early. But, because ICD-10 cannot be used until October 1, 2014, software will need to be able to support ICD-9 and ICD-10 simultaneously during the transition. Also remember that some payers such as workers' compensation and auto insurance companies may continue to require ICD-9 codes after the compliance date. So, software will need to continue to support the older code set.

One way that practice management software can manage the billing of dual ICD-9/ICD-10 code sets is by down-converting ICD-10 codes to ICD-9 for the period of time prior October 1, 2014, for most payers and indefinitely for non-covered payers. Up-converting from ICD-9 to ICD-10 is not as straight-forward, since a single ICD-9 diagnosis code could yield several ICD-10 codes from which to choose. For that reason, it is preferable for doctors to diagnose using ICD-10 whenever possible and convert to ICD-9 only as needed.

ICD-10 Resources

Fortunately, there are many educational resources available to health care providers for preparing to the migration to ICD-10. CMS has created an entire website devoted to the transition to ICD-10 and is the best place to start. Type www.cms.gov/icd10 into your browser and you will find a wealth of information including the latest news, educational papers, time lines and FAQs.

The American Chiropractic Association has also provided valuable ICD-10 information for its members at www.acatoday.org. The ACA website offers comparisons of ICD-9 to ICD-10, tools for finding and selecting ICD-10 codes, links to additional resources and more. Additional information including instructional videos will be posted to the ACA website as we get closer to the compliance date.

The thought of abandoning the well-known and comfortable ICD-9 diagnosis codes and learning an entirely different set of codes seems overwhelming. But, armed with a little knowledge and a good plan, chances are you will successfully make the transition and live to tell about it.

References

1. "45 CFR Part 162; HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards To Adopt ICD–10–CM and ICD–10–PCS." 74 Federal Register 11 (16 January 2009), pp. 3328-3337.
2. "45 CFR Part 162; Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for the International Classification of Diseases, 10th Edition (ICD–10–CM and ICD–10–PCS) Medical Data Code Sets." 77 Federal Register 172 (5 September 2012), p. 54665.
3. Centers for Medicare and Medicaid Services. The ICD-10 Transition: An Introduction.
4. Center for Medicare and Medicaid Services. FAQs: ICD-10 Transition Basics.
5. Centers for Medicare and Medicaid Services. General Equivalence Mappings.
6. Centers for Medicare and Medicaid Services. ICD-10-CM/PCS: Myths & Facts.
7. Centers for Medicare and Medicaid Services. The ICD-10 Transition: Focus on Non-Covered Entities.