ICD-9 >> ICD-10

More than changing codes

By Cindy Hughes, C.P.C., C.F.P.C., P.C.S.
AAFP Coding and Compliance Specialist

Hopefully by now your practice has the transition to the HIPAA 5010 transaction standards completed or well underway. If not, this change in how you transmit and receive electronic transactions such as claims and eligibility verifications is coming fast with a deadline of Jan. 1, 2012. It is past time to make this transition and begin another one: the change to ICD-10 diagnosis coding.

Though the Oct. 1, 2013 deadline for beginning to use ICD-10 diagnosis codes in all of the places where you currently use ICD-9 may seem far into the future, many practices, hospitals, and health plans have recognized the need to plan and begin the transition now.

Why so early? Because this is not just an updating of superbills or computer databases. The initial implementation of the HIPAA standards pales in comparison to the implementation of ICD-10. Here are a few reasons why:

• ICD-9 currently includes 14,432 diagnosis codes. ICD-10 currently includes 69,368 diagnosis codes. A one-to-one match of the codes is not possible in most cases.
• Superbills may be unworkable. The 164 ICD-9 codes from the Family Practice Management superbill were converted to ICD-10 by a health plan. The result was a change from one page to eight pages of codes.
• ICD-10 codes include alphanumeric characters including capital letters “I” and “O.” These must not be confused with the numerals “1” and “0.” The addition of alphabetic characters may slow down data entry.
• Diagnosis codes are used not just in the billing office but in clinical care when ordering laboratory tests, pre-authorizing services, and reporting for quality or public health purposes. Updates will be required in many areas of the practice.
• Unlike the move to HIPAA 5010, the ICD-10 transition has a single start date. You cannot use ICD-10 codes in relation to services provided prior to Oct. 1, 2013, and you cannot use ICD-9 codes for services provided on Oct. 1, 2013, or thereafter.
• The format of the codes is longer and more complex. Staff will need training on the use of the new code set.
• System upgrades, production of new reference materials, and staff training may require consideration in your budget planning.
• The effect of ICD-10 transition should be considered in relation to adoption of EHRs, participation in Medicare quality reporting initiatives, and other changes that your practice may be initiating.

So where do you begin and where can you learn more? You can find general information about ICD-10 and an example of a transition plan on AAFP’s website at www.aafp.org/online/en/home/practicemgt/codingresources/icd10cm.html.

You can also find the most up-to-date release of ICD-10 from the National Center for Health Statistics at www.cdc.gov/nchs/icd/icd10cm.htm. The 2012 version is expected to be released early next year and will be the version that is adopted on Oct. 1, 2013. Because the Centers for Medicare and Medicaid Services have enacted a freeze on the ICD-10 code sets from Oct. 1, 2011, through Oct. 1, 2014, the 2012 update is the last until October 2014, with rare exceptions for new diseases. There will also be no update to the ICD-9 diagnosis codes on Oct. 1, 2012, unless there is a new disease that needs to be included immediately such as a new strain of influenza. The intention of this freeze is to provide stability in the code sets while the entire health care system transitions from ICD-9 to ICD-10.

You will find that the conventions of ICD-10 are similar to ICD-9. It is still necessary to consult both an index and a tabular section to arrive at the appropriate code for a condition. There are still tables of neoplasms and of drugs and chemicals. Also carried over from ICD-9 are the sections of codes to identify external causes (ICD-9 E codes) and factors influencing health status and encounters for health services (ICD-9 V codes).

Differences come not only in the volume and expandability of codes but also in their structure. ICD-10 starts with a base code that typically includes an alphabetic character followed by two numbers such as I10, which represents hypertension in ICD-10. However, the code set is not limited to this format and includes some codes that include alphabetic characters in the second or third digit such as M1A.00 for idiopathic chronic gout, unspecified site. Codes then can extend to seven digits with some including an X as a placeholder for later expansion of a code category such as S06.0x1 for reporting a concussion with loss of consciousness of 30 minutes or less. Codes for injuries and certain other conditions such as S06.0x1 also require a seventh digit that identifies specifics about a condition such as whether the encounter is the initial encounter (A) with you for this condition, subsequent encounter (D), or sequela (S) (called late effects in ICD-9). To report a complete code for the initial encounter to treat a concussion with loss of consciousness would be S06.0x1A.

These examples show some of the differences that must be accommodated in the transition to ICD-10. Though the code set is larger and more complex, the increased adoption of electronic health records, mappings from SNOMED (Systematized Nomenclature of Medicine) terminology to ICD-10, and the availability of other electronic databases may lessen the challenges. However a change this big cannot be managed at the last minute and early planning is your best defense against payment delays and information inaccuracies.

So what are the first steps? Planning, familiarizing, and inventory should come first.

1. Early decisions might be whether a staff person or physician will take the lead in overseeing the transition. This person can help coordinate areas such as information technology upgrades, billing and coding workflow, and clinical documentation.
2. The leader and other key team members should become familiar with the ICD-10 code set as it pertains to your practice and use this knowledge to inform changes to tools, resources, and systems.
3. Determining where ICD-9 codes are used and by which staff will be key to preventing gaps in your transition plan. By making an inventory of who uses the codes and for what purposes, you can determine who needs training and at what level, what resources or tools must be updated or replaced, and which electronic systems may require updates.

With this information, you can begin an estimated budget and timeline. Upgrades of software and hardware, if required, may be included in your maintenance contract, but it is important to verify this early and seek information on vendor plans for upgrades as soon as possible. If coding and billing are performed in-house, there may also be need to either temporarily bring in extra help at the time of the transition or plan for payment delays should they occur.

AAFP did not support this change at this time, but you can count on TAFP, AAFP, and Family Practice Management to support you with information and resources to help along the way.

ICD-10 resources

Find information about ICD-10 and an example of a transition plan on AAFP’s website: www.aafp.org/online/en/home/practicemgt/codingresources/icd10cm.html.

Go to the National Center for Health Statistics to find the most up-to-date release of ICD-10: www.cdc.gov/nchs/icd/icd10cm.htm

Access an archive of the Centers for Medicare and Medicaid Services May 18 national provider call in podcast or video slideshow form. Go to the ICD-10 teleconference webpage on the CMS website at http://www.cms.gov/ICD10/Tel10/itemdetail.asp?itemID=CMS1246998; the four podcasts with corresponding written transcripts are available in the “downloads” section of the page and the video slideshow presentation is available in the “related links outside CMS” section.

Cindy Hughes is AAFP’s coding and compliance specialist. Contact her at (800)274-2237, ext. 4176, or chughes@aafp.org.