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ICD-10: What to Expect after the Deadline


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

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" (bit.ly/ICD10-references) 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 joint press release:


AMA and CMS collaboration / frequently asked questions:



Maria N. Ward, M.Ed, RHIT, CCS-P, is a director of health information management practice excellence at AHIMA. She can be reached at maria.ward@ahima.org.

© 2015 American Health Information Management Association (AHIMA). Reprinted by permission.

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