Maria N. Ward, M.Ed

The Ninth Revision of the International Classification of Diseases (ICD) has been in use for many decades until it became apparent that the system needed a complete overhaul. For over 35 years the United States has used the same classification system for reporting diagnoses and finally, after four implementation dates, three delays, and much political bureaucracy, ICD-10 will have its day.

So now what? That depends. Did you move ahead and take all the recommended steps outlined by CMS, or did you procrastinate in hopes that ICD-10 would fall by the wayside? This is where the rubber meets the road. ICD-10 is here and now all healthcare providers must face that fact. No one knows for sure what will happen at this point, as this is a new change and, like all changes, no one knows the outcome.

Up to this point, successful implementation has been the focus, and physicians have been granted some additional help in this area thanks to the coordinated efforts of CMS and the AMA. Throughout the course of events leading to the final implementation date, CMS has offered an abundance of resources to all providers. The "Road to 10" (

) has been specifically aimed at the smaller physician practice, and training videos have been created and are available on the CMS website. Help can be found on implementation, documentation improvement, and many other topics to ensure a smooth transition. Now additional resources will be available for physician practices.

Beginning Oct. 1, 2015, the CMS ICD-10 Coordination Center will be set up to handle all communication and collaboration related to implementation of ICD-10, and will house the ICD-10 Ombudsman. According to the CMS' website (bit.ly/ICD10-ombudsman), "The ombudsman will work closely with representatives in CMS's regional offices to address physicians' concerns." The intent of the Coordination Center and the ICD-10 Ombudsman is to "quickly identify and initiate resolution of issues that arise" during the transition to ICD-10. There will be a standard means of submitting questions to the ombudsman, who will help to review and direct physician and provider questions to the most appropriate respondent.

In addition to providing an ombudsman, CMS will allow for flexibility when it comes to auditing post-payment physician claims, as well as for the quality reporting process related to the new ICD-10 codes. So what exactly does this flexibility mean to the physician practice? One thing for certain, it does not mean a delay.

Starting Oct. 1, 2015, all claims must be submitted using valid ICD-10 codes for physician services, along with the applicable Current Procedural Terminology (CPT) codes. CMS continues to encourage accurate coding, which means coding to the greatest degree of specificity possible. In order to assist physicians and other eligible professionals, CMS has stated that Part B claims billed under the physician fee schedule will not be denied based on the lack of specificity in the code so long as the code is a valid code and is from the correct code family. This is the only reason a claim will not be denied. A claim can, however, continue to be denied and chosen for review for many other reasons that already exist, including National Coverage Determinations (NCD) and Local Coverage Determinations (LCD).

In July, CMS clarified what constitutes the correct code family. According to CMS, the correct code family means that the valid ICD-10 code submitted is a complete code and falls into the correct three-character code category. For example, the three-character code I10 is a valid three-character code, and is the code for essential hypertension. There are no other codes in this category. The same is true for B20, human immunodeficiency virus (HIV) disease. However, greater specificity is abundant in ICD-10, especially related to laterality, and laterality is one exception to the flexibility guidance. The FAQs also state that the NCD and LCD coverage policies "will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality." Because there are ICD-10 codes for right, left, and bilateral, that level of specificity will be expected when claims are submitted, even though laterality was not available in ICD-9.

Given the flexibilities agreed upon by CMS and AMA, the possibility of claim denials is still inevitable. Processes for claim review and appeal are still the same, and the need to have well-trained staff on board is evident. Training efforts will likely not be on the downhill slide, especially given the ICD-10 code freeze since 2010.  By Oct. 1, 2016, the mounting changes that have accumulated over the past six years will surely require ongoing education for all staff involved, from patient intake to appeals. ICD-10 is here and all providers must embrace it and move forward. The buildup and angst has come and gone, and claims continue to roll in and roll out as we now begin to accept this new system and look forward with great anticipation to the release of ICD-11.

AMA and CMS collaboration / frequently asked questions:

 is a director of health information management practice excellence at AHIMA. She can be reached at 

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It's all been about successful implementation up to Oct. 1, but soon practices should focus on life after ICD-10 becomes a reality.

ICD-10: What to Expect after the Deadline

In the physician practice, it cannot be stressed enough that only ICD-10 will be utilized come Oct. 1, 2015. The first thing that needs to be understood is what exactly is changing in regard to the diagnosis codes in ICD-10.

ICD-10 has gone from 17 chapters to 21 chapters. While this might sound like the cause of all the additional codes, it really is not. In ICD-9, there were the V-codes and E-codes that were not classified as "chapters." That accounts for two of the four new chapters. The other two are the result of diseases of the eye and ear each being promoted out of the nervous system chapter. There are also some codes that have been reclassified into more appropriate categories based on current medical knowledge.

In contrasting the two code sets, ICD-10 has changed how injuries are classified. They are now grouped by the body site injured and then by the type of injury, whereas ICD-9 only classified injuries by type. To allow for future expansion, ICD-10 codes can be as small as the three-character category code and as information rich as a seven-character code that includes laterality, severity, and episode of care. Additionally, ICD-10 has switched over to alphanumeric versus the straight numeric ICD-9.

Documentation has been touted as one of the biggest challenges with ICD-10, which is understandable considering the need for more specificity in order to obtain the most accurate code to describe the patient's condition. The more precise the description of a patient's condition, the more detailed the code choice can be. This leads to better data for outcomes reporting, research, and public health statistics, just to name a few benefits. The goal of documentation improvement is not to increase the amount a provider charts on a patient. The goal is to give an accurate depiction of the symptoms that lead to diagnosis, and the treatment course chosen to most effectively care for the patient. When looking at the groups of quality measures in the Physician Quality Reporting System (PQRS), ICD-10 offers the physician a greater number of combination codes to more succinctly report the more common etiologic and manifestation relationships.

In ICD-10, there was a significant change in the diabetes mellitus codes. In ICD-9, there was only the 250 category. With ICD-10, there are five categories, but the most significant change is the combination codes that were created. As mentioned earlier, there have been a number of additional codes added to ICD-10, and diabetes is one of the places where that occurred. These added combination codes actually reduce the number of codes to report. Rather than using two codes to describe a single condition, the diabetes combination codes describe both the etiology (diabetes) and the manifestation (such as, glaucoma) all in one code. A perfect example of this is type 2 diabetic retinopathy with macular degeneration. In ICD-9, it would have taken three codes to capture every detail of this condition. In ICD-10, it only takes one code. So if there is type 2 diabetic retinopathy with macular degeneration, then there is also a type 1 diabetic retinopathy with macular degeneration. Sufficed to say, the same would be true for each of the other three categories of diabetes mellitus. It is for this reason that, when looking in the 2015 PQRS Measures Group Specifications Manual, there is going to be a longer list of possible codes the diabetes group. The number of reportable diabetes codes for Jan. 1, 2015, through Sept. 30, 2015, is 54. Beginning Oct. 1, 2015, there are a total of 92 reportable diabetes codes. Again, these codes provide more granularity, and therefore improved data.

While some providers may be alarmed at the increased availability of these more definitive code descriptions, there is a change with ICD-10 many will be pleased about. No longer will they be inundated with queries asking if the diabetes is controlled or uncontrolled. This classification is removed from ICD-10. However, if the terms "inadequately controlled," "out of control," or "poorly controlled" are used in documentation, coders will be guided by the ICD-10 index to use the type of diabetes with hyperglycemia.

Another reportable diagnosis in the PQRS Measures Group is asthma. While the number of reportable diagnoses for asthma has also increased when comparing ICD-9 to ICD-10, the number of codes is significantly lower. There is only an increase of four additional codes in the list of reportable asthma diagnoses. This change is attributable to the addition of terms that more appropriately reflect the current clinical classification of asthma. The terms that have been added are "mild intermittent," "mild persistent," "moderate persistent," and "severe persistent." Providers that see a high number of asthma patients should be aware of these classifications and utilize an appropriate source to make consistent diagnosis and treatment decisions based on the chosen source.

On Dec. 10, 2014, a joint presentation was done by CMS and the American Health Information Management Association (AHIMA). The following list was provided as documentation focus areas:

• Changes in timeframes associated with familiar codes

By reviewing the 2015 PQRS Measures Group Specifications Manual and focusing on this list of areas for documentation improvement, any physician practice can improve not only their documentation, but also demonstrate improved quality of care by providing a clear picture of the patient throughout the care continuum.

Now that some of the groundwork has been laid, it is time to build on the foundation of strong documentation. Every ounce of clarity noted in the provider documentation builds a complete picture of the patient's health, history, treatment, and quality care. Additional steps for preparation are easily accomplished when these building blocks are in place.

• AHIMA. ICD-10-CM/PCS Implementation Toolkit: 

• AHIMA. ICD-10 for Physicians and Clinicians: 

http://www.ahima.org/topics/icd10/physicians

• CMS Provider Resources - Road to 10: 

http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

Make sure your practice is ready for changes in documentation analysis and quality reporting tied to the ICD-10 coding transition.

Author | Maria N. Ward, M.Ed

Articles

ICD-10: What to Expect after the Deadline

ICD-10 Documentation and Quality Reporting Changes