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ICD-10 Ramps Up

Earlier 2010, officials at the Centers for Medicare and Medicaid Services (CMS) declared that Oct. 1, 2013 would be the firm implementation date for ICD-10, the newest iteration of the International Classification of Diseases (ICD) coding system used on medical claim forms.

The question then became how to handle the transition from ICD-9 to ICD-10, especially when it came to updating each set of codes during the transition.

CMS officials proposed a “limited freeze,” under which the last regular, annual updates to both ICD-9 and ICD-10 would be made on Oct. 1, 2011. A year later, on Oct. 1, 2012, limited changes would be made to both sets of codes to account for new technologies and diseases.

The next year, on Oct. 1, 2013, limited changes would again be made — but only to the ICD-10 codes, as ICD-9 would be phased out. One year later, on Oct. 1, 2014, the regular annual update to ICD-10 would begin.

In September, the ICD-9-CM Coordination & Maintenance Committee announced that the “limited freeze” proposal had been accepted, paving the way for the transition from ICD-9 to ICD-10 to begin in earnest.

Although ICD-10 codes differ from ICD-9 in several ways — such as the number of characters used in each code and the use of an “x” placeholder — the biggest difference between the two coding sets is the number of codes involved. Because they are more complex and detailed, ICD-10 includes 69,099 diagnosis codes compared with only 14,315 ICD-9 codes.

So far, providers’ progress on switching over to the new codes has been varied, according to Kathy DeVault, manager of professional practice resources at the American Health Information Management Association, a Chicago-based organization for health information management professionals.

“We did an audio conference in early August, and one of our survey questions was ‘How many of you have an [ICD-10] implementation team?'” said DeVault, who is based in Fort Collins, Colo. “And 60% did not; that number seems kind of high.”

On the other hand, one woman that DeVault met at a meeting in early December, who is in charge of the transition for more than a dozen hospitals, had already put together an education plan for her coders.

Payers also are getting ready, DeVault said. “At a convention this past fall, we had a presenter from UnitedHealth [Group] who was one of the project managers for the ICD-10 transition — she is very excited and very organized, and they’re determined to use the full amount of implementation time available.”

Hand-in-hand with preparing for ICD-10 is getting ready for the new 5010 protocol for submitting electronic claims to Medicare and other payers. The 5010 protocol, which goes into full effect on Jan. 1, 2012, replaces the current protocol, known as 4010.

Physicians and other providers who will be using the 5010 protocol have until the end of December to complete internal testing if they want to achieve Level 1 compliance with the new format, DeVault said.

Beginning the next day, on Jan, 1, 2011, providers who are ready can begin submitting claims to CMS using the 5010 protocol. Starting on Jan. 1, 2012, Medicare will no longer accept electronic claims that use the 4010 protocol; only 5010 claims will be accepted.

For providers who start using 5010 early, there is a bonus, DeVault pointed out: the new protocol allows for up to 25 diagnosis codes and 25 procedure codes per claim, a big jump from the current limit of nine diagnosis codes and six procedure codes.

“We have some really sick patients, and as a coder we want to receive the best reimbursement we’re entitled to in our facility,” she said.

Providers who have questions about either ICD-10 or the 5010 protocol can find resources at this website.

Source: Medpage Today



On August 22, 2008, the Federal Government proposed a new rule that would require all physician practices and clinical laboratories to use a new coding set – the ICD‐10‐CM code set – as the standard code set for coding diagnoses on all HIPAA standard transactions.

An update of the ICD‐9 code set, the proposed rule expands diagnosis codes by a factor of 5, enabling greater specificity in the coding of diagnoses, allows for expansion in future years, and improves the description of current technologies. The proposed implementation of the code set would have a profound impact on the operations of physician practices and clinical laboratories.

Staff Education & Training.

Clinical and administrative staff will require significant time simply to learn about the new codes. As the new rule is not a simple substitution of one code set for another, the learning curve is expected to be quite steep for both clinicians and administrative staff, particularly for small‐ and medium‐sized organizations that do not employ professional coders. Detailed training will be required across‐the‐board for clinical and administrative staff involved in documenting patient activities, coding of medical and administrative records, information technology, health plan relations, and contracts. In addition, learned patterns and relationships among codes would have to be re‐learned because of the changed structure and organization of the code set.

Business‐Process Analysis of Health Plan Contracts, Coverage Determinations, & Documentation. Once the new ICD‐10 rule is understood by clinical and administrative staff, physician practices and clinical laboratories would need to undertake an assessment of the ICD‐10 mandate’s impact on business processes, including provider‐health plan contracting, coverage determinations, and contracting. Health plans may modify provider contracts to comply with the greater specificity required in the ICD‐10 mandate and adjust payment terms accordingly. Coverage determinations may also be revised in accordance with new diagnostic codes and additional documentation required to a health plan to support a patient’s treatment plan.

Changes to Superbills.

Most physician practices use “superbills” – documents provided to health plans and other payers that specify medical services provided, why they were necessary, and the accompanying CPT and ICD codes – as the basis for billing and reimbursement. With five times as many codes as the previous ICD coding iteration, an ICD‐10 mandate would require significant changes to existing superbills and/or spur some practices to move to an electronic medical record (and absorb corresponding software costs).

IT System Changes.

Once physician practices have completed their business‐process analyses, it will be necessary to incorporate the ICD‐10 changes into any IT products that would intersect with it, including a practice management system vendor, an electronic health record vendor, a billing service vendor, and others. For example, physicians’ practice management systems, software modifications will be necessary in both the insurance coverage system and in the billing system. Another potential area for concern is that practices will have to assure that their billing services and clearinghouse vendors are compliant with ICD‐10 coding as well. These and many other changes will all have to be tested, operationalized, and integrated into the day‐to‐day operations of physician practices.

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