ICD-10: Introduction and
Preparation for Transition
Presented by Prestige Health Choice
Fall 2015
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contained
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be disclosed without the prior consent of the directors of Prestige Health Choice.
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Agenda
– What is ICD-10?
– What are the benefits of ICD-10?
– What are the differences between ICD-9 and ICD-10?
– Timeline for implementation and deadlines for claims
– Important links, trainings and additional information
– Frequently asked questions?
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So, What is ICD-10?
ICD-10-CM is the United States' clinical modification of the World Health Organization's
(WHO) International Classification of Diseases (ICD) Tenth Revision. It is used to classify
diseases and causes of illness recorded on health records, claims, and other vital
information. ICD-10-PCS is the procedure classification system used to report hospital
inpatient procedures.
The U.S. Department of Health and Human Services ("HHS") issued a final ruling in
2009 that requires covered entities (health plans, health care providers, and health
care clearinghouses) that conduct electronic HIPAA standard transactions to move
from ICD-9 to the next generation ICD-10 code sets by October 1, 2014. The transition
does not affect the Current Procedural Terminology (CPT®) code set, which will
continue to be used for outpatient services.
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Benefits of ICD-10
ICD-9 has nearly reached its capacity for
growth at approximately 13,000 codes.
With the implementation of ICD-10, the
number of existing codes will increase to
approximately 68,000. Due to the
increased specificity of ICD-10 codes,
there will not be a direct crosswalk from
ICD-9 to ICD-10.
More detailed codes will help track
health care trends and help analyze
Quality measures
ICD-10 is more clinically accurate than
ICD 9 and allows for greater detail within
a single diagnosis code.
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ICD-10-CM and ICD-10-PCS
ICD-10 consists of two parts:
ICD-10-CM (Clinical Modification)
refers to ICD-10’s diagnosis coding
system.
ICD-10-PCS (Procedure Coding System)
refers to ICD-10’s surgical procedure
coding system.
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ICD-9-CM and ICD-10-CM (Clinical Modification)
– ICD-9-CM and ICD-10-CM have the same hierarchical structure; however, there are
changes in the organization of the code set.
– ICD-10-CM allows for more characters (from three to seven) and requires a decimal
point.
– ICD-10-CM codes are alphanumeric, which adds laterality and provides a greater
level of specified.
Structure of ICD-9-CM
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Structure of ICD-10-CM
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ICD-9-PCS and ICD-10-PCS (Procedure Coding System)
PCS is a type of surgical procedure coding new to ICD-10 and was created for use in
inpatient hospital settings ONLY.
PCS codes require all 7 characters, unlike current surgical procedure codes (using the ICD-9
CM coding) that require only 3-4 characters.
Each character is either alpha (not case sensitive) or numeric.
Letters O and I are not used to avoid confusion with numbers 0 and 1.
Structure of ICD-10-PCS
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Other Important Changes for ICD-10-CM
Importance of Anatomy: Injuries are grouped by anatomical site rather than by type of injury
Incorporation of E and V Codes: The codes corresponding to ICD-9-CM V codes (Factors
Influencing Health Status and Contact with Health Services) and E codes (External Causes of
Injury and Poisoning) are incorporated into the main classification rather than separated into
supplementary classifications as they were in ICD-9-CM
New Definitions: In some instances, new code definitions are provided reflecting modern
medical practice (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8
weeks)
Restructuring and Reorganization: Category restructuring and code reorganization have occurred
in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and
disorders that are different from ICD-9-CM
Reclassification: Certain diseases have been reclassified to different chapters or sections in order
to reflect current medical knowledge
To learn more about ICD-10 and the changes surrounding the transition, please visit
http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10MythsandFacts.pdf.
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What Happens on October 1, 2015?
All health services rendered on or after October 1, 2015 must utilize the updated ICD10-CM diagnosis codes. All inpatient health services rendered on or after October 1,
2015 must utilize the updated ICD-10-PCS procedure codes. The usage of the codes are
date of service driven for outpatient services and discharge date driven for inpatient
services. All health services rendered before October 1, 2015 will require the use of
ICD-9 codes.
Claim and encounter transactions with services rendered on or after October 1, 2015
will require the use of ICD-10 codes. Claim and encounter transactions with services
rendered before October 1, 2015 will require the use of ICD-9 codes. Claim and
encounter transactions with ICD-9 codes and dates of service prior to October 1, 2015
may be received up to 18 months after the service date to meet timely filing rules.
Claim types include: Inpatient, Outpatient, Professional Physician, Pharmacy, Lab,
Imaging, Dental, Vision, Durable Medical Equipment (DME), and Transportation
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ICD Code Set
The table below identifies the ICD code set to use for
each claim type based on date of discharge for inpatient
claims and date of service for all other claim types.
Prestige will follow the CMS guidelines for claims that
cross the 10/1/15 implementation date: claims must
contain only ICD-9 codes OR only ICD-10 codes.
Prestige will require providers and subcontractors to
split claims as needed to meet the requirement.
Please note: claims submitted
after 10/01/2015 using ICD-9
– The claim will reject at the
Emdeon Gateway. It will not
enter the AmeriHealth system,
and will not be processed.
– The provider will need to
correct the data on the claim
and resubmit.
– The claim has been rejected,
not denied; therefore, will not
appear in claim history data.
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ICD-10 Step 1: Make a Plan
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ICD-10 Step 2: Train Your Staff
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ICD-10 Step 3: Update Your Processes
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ICD-10 Step 4: Talk to Your Vendors and Health Plans
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ICD-10 Step 5: Test Your Systems and Processes
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ICD-10 Resource Center
Important links and information
Prestige Health Choice ICD-10 Resource Center
http://www.prestigehealthchoice.com/provider/itn/resources/icd10-resource-center.aspx
AHCA FAQs
http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/ICD10/ICD10_FAQ.pdf
AHCA ICD-10 Training Portal
http://portal.flmmis.com/flpublic/Provider_AgencyInitiatives/Provider_ICD10/Provider_ICD10Training/tabid/93/desktopdefaul
t/+/Default.aspx
CMS Training
http://www.cms.gov/Medicare/Coding/icd10/
CMS Clinical Concepts for Family Practice
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsFamilyPractice1.pdf
World Health Organization
http://www.who.int/classifications/icd/en/
Centers for Disease Control and Prevention
http://www.cdc.gov/nchs/icd/icd10.htm
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The information in this document is confidential and should not be disclosed outside of Prestige Health Choice. It may not be reproduced in whole, or in part, nor
may
any ofHealth
the information
contained therein be disclosed without the prior consent of the directors of Prestige Health Choice.
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Choice
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