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On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10-CM/PCS code sets. ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPPA), not just those who submit claims to Medicare or Medicaid. Federal regulations require everyone covered by HIPPA to use ICD-10-CM/PCS code sets for dates of service or date of discharge for inpatients that occur on or after October 1, 2015. The ICD-10-CM diagnosis code set must be used in all healthcare settings. The ICD-10-PCS procedure code set is used only in inpatient hospital settings to code inpatient procedures.

Benefits of ICD.10

ICD-10 will help providers more completely and accurately tell the clinical story of the patient, which will produce better data for:

Measuring quality, safety, and efficacy of care
Processing claims for reimbursement
Conducting research and clinical trials
Setting health policy
Operational and strategic planning
Designing healthcare delivery systems
Monitoring resource utilization
Preventing and detecting healthcare fraud and abuse
Improving clinical, operational, financial performance
Tracking public health and risks
What is different about ICD.10?

The ICD.10 system consists of over 68,000 codes, compared to approximately 13,000 ICD-9 codes. ICD-10 differs from ICD-9 in its organization and structure, code composition, and level of detail.

Many of the new codes are related to the laterality of the body part. For example, these new codes specify right knee, left knee, or bilateral knees. More specific codes will lead to increased patient safety and better outcomes. The number of payer denials may be decreased, since more information can be provided about a patient visit through coding that conveys medical necessity for the billed service. The following table summarizes the major improvements and changes between ICD-9 and ICD-10 diagnosis codes:

ICD-9-CM Diagnosis Codes

No Laterality
3-5 digits
First digit is alpha (E or V) or numeric
Digits 2-5 are numeric
Decimal is placed after the third character
No placeholder characters
14,000 codes
Limited Severity Parameters
Limited Combination Codes
1 type of Excludes Notes
ICD-10-CM Diagnosis Codes

Laterality –
Right or Left account for >40% of codes
7 digits
Digit 1 is alpha; Digit 2 is numeric
Digits 3–7 are alpha or numeric
Decimal is placed after the third character
“X” placeholders
69,000 codes to better capture specificity
Extensive Severity Parameters
Extensive Combination Codes to better capture complexity
2 type of Excludes Notes
ICD Preparation

Having an ICD-10 implementation strategy that includes early preparation, adequate training, and proper testing will help mitigate potential problems before the October 1 implementation date that could result in claim rejections and payment delays. Some areas that facilities should consider include:

The impact the transition will have on the facility
Identification of the facility ICD-10 implementation team
The resources available to support tasks, such as training and system changes
Software and hardware requirements. Facilities should work with their software vendors to ensure timely preparation for the changes required to their electronic documentation and billing systems
Compatibility with existing systems
Processes that need updated: clinical documentation systems, paper forms/templates, policies and procedures
Education and training needs at all levels of the organization.
Internal testing of systems and processes
External testing with partners

Shelly Maffia, RN, MSN, MBA, NHA is a Clinical Consultant for Proactive Medical Review & Consultants, LLC located in Evansville, IN and an AHIMA approved ICD-10-CM/PCS Trainer.

Proactive therapist, nurse and billing consultants specialize in skilled rehabilitation programming and Medicare compliance. Proactive provides risk assessment, medical record audit and Medicare compliance consulting to SNF/NF providers throughout Indiana and Kentucky. smaffia@proactivemedicalreview.com