Ch. 03


When the ICD-10-CM transition happens in 2013, almost everyone in the medical profession will be affected. It applies to all areas of health care under the provisions of the Health Insurance Portability and Accountability Act (HIPAA), not just those under Medicare and Medicaid. Thus, providers, vendors and payers alike need to understand how the new coding system works and the effects it’ll have on their daily procedures. Here’s a guide to how it will impact you:

For Providers:

Clinics, hospitals, independent physicians, etc.

ICD-10 is a broad change, which will probably affect the way paperwork is done in almost all aspects of the medical profession. Essentially, anywhere ICD-9 code is currently in use, changes will have to be made to accommodate ICD-10. That means documentation for practice management, electronic health records, public health and quality reports, clinical documentation, encounter forms and even contracts with vendors and payers. Contracts with payers especially should be reviewed with care, as the change in documentation could have a big impact on which diagnoses they choose to reimburse for and why. Be sure to have a conversation with all of your payers as early as possible, and get on the same page as your software vendor, too. Ask if your contact includes upgrades, or, if you’re purchasing a new system, make sure that it is ICD-10 compatible.

The implementation of ICD-10 will affect hospitals more than other medical businesses. This is because hospitals will have to comply with both ICD-10-CM for diagnoses, and ICD-10-PCS for inpatient procedures, while smaller clinics only have to worry about the diagnoses. The change does not affect CPT coding.

While the official implementation deadline isn’t until October 1, 2013, all medical establishments should be working toward installing the new code and training employees in its use now, so that there’s plenty of time to test it out. Be sure to budget for the extra time and money this implementation will take, including employee training and the purchase of new software systems. Also, keep in mind that the deadline for implementing the new 5010 transaction standards for bills and payments is January 1, 2012. Be sure to review your contracts with payers, and run several test transactions to make sure the new standards are working properly before the compliance deadline.

Common Concerns

There has been some concern from the medical community about ICD-10’s specific diagnoses and the extra complexity involved in using them, but there’s nothing to worry about. The new coding system has the same broad codes ICD-9 did, with the additional codes in case of more specific diagnoses, so no extra tests will have to be preformed to determine classification. Plus, the new codes are formatted in the same way as the old ones, except instead of 3-5 characters, they have 3-7, which allows for greater specificity in recording patient information. Adapting existing superbills to ICD-10 should be fairly straight-forward, especially with the crosswalk systems provided to help in the transition.

Employee Training

In preparing for this transition, the most important thing is to make sure that all employees affected by the change are prepared to deal with it, according to their level of contact. Consider dividing employees into categories based on how much training they’ll need, from those who only need a basic understanding (like nurses) to those who need to be fully certified (like coders). If you have a small practice, consider teaming up with other small practices to help cut the costs associated with training. Have trained employees help train others (i.e., have coders teach nurses the basics), so that you can save on the cost of bringing in an outside professional.


For Vendors:

Software providers, clearinghouses, third-party billing services, etc.

While the ICD-10 system implementation deadline isn’t until the end of 2013, you should be preparing for it now. Even more importantly, you should already be coding for the 5010 transaction standards, because their implementation is less than 6 months away. Because ICD-10 is mandatory for all medical establishments under the HIPAA, if you don’t start using it now, your software will be obsolete in just a couple years.

Because the change is highly technical, medical providers and payers will be looking to you, the vendor, for guidance and help with the implementation. Make sure to discuss the changes with your clients, so that they understand what they need to do to help you get the software up and running well before the due date. It’s also important that you be clear about whether or not the upgrades are covered under existing contracts, because the extra expense could be a deciding factor in whether or not a provider can work with you. Pay particular attention to the changes necessary for 5010 transaction standards compliance, because reimbursement issues will be the biggest obstacle to avoid. Providers want their software to work with minimal difficulty, so keep that in mind when you are writing and installing it.


For Payers:

Insurance companies, third-party funding agencies, etc.

Payers will have to update their software to match ICD-10 and 5010 standards by the same deadlines as providers and vendors, though the process is not as urgent due to less of a need for training. The biggest issue for payers is going to be running ICD-10 code through ICD-9 compatible systems. Medical providers are slowly transitioning to ICD-10, so you may find that the new code comes in before you’ve had time to update your software to handle it.

For that reason, the CDC has developed General Equivalence Mappings (GEMs) to help translate ICD-10 code into ICD-9 code. The system is not perfect, so it is still in your best interest to get new software that uses ICD-10 standards, but in the meantime the GEMs will help ease the transition. The GEMs work by a one-to-many cataloging system, so one ICD-10 code may translate into two or more ICD-9 codes. For this reason, you have to give the program extra space to save the extra codes.

GEMs will be useful for payment systems, quality measures, risk adjustments and trend data in research applications, though you should still try to update these systems to ICD-10 as soon as possible.


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