Ch. 02

Frequently Asked Questions

What is ICD-10?

ICD-10 is the International Classification of Diseases, Tenth Edition. It is a diagnostic code system that is used in nearly every country in the world, except the United States. Developed by the World Health Organization, ICD-10 was implemented in 1993 in order to replace the ninth edition. This is a strictly diagnostic coding system, though sometimes it is inaccurately intended as ICD-10-CM/PCS.

The official guidelines for coding and reporting are available in PDF format at the CDC website.

What is ICD-10-CM?

Often, ICD-10 refers to the clinical modification of the code, which is abbreviated as ICD-10-CM. The clinical modification system was developed by the Center for Disease Control and Prevention, which already uses the code for mortality reporting. ICD-10-CM will replace the currently used ICD-9-CM. The official transition to ICD-10-CM will occur on October 1, 2013. This date is not flexible, and there is no plan for extension; it must be implemented on time.

What is ICD-10-PCS?

ICD-10-PCS is a separate designation for the procedural coding system. It was developed for documenting the procedural services of hospitals. Developed for the Centers for Medicare & Medicaid Services (CMS) by 3M Health Information Management, this system will replace ICD-9-CM Volume 3. Hospital inpatient procedures involving operating rooms, nursing services and the like will use ICD-10-PCS. Other common procedures that are not limited to inpatient services such as laboratory tests or educational seminars are not included. Physician services will continue to utilize CPT® (Current Procedural Terminology) codes for outpatient procedures. Though it was created by 3M Health Information Management and not WHO, it is meant to operate in conjunction with ICD-10-CM.

Why is the United States making the transition to ICD-10-CM/PCS?

ICD-9-CM has reached its limit. The scientific organization of ICD-9-CM means that there are only ten subcategories available for each three-digit category. Most of these have already been used to assign diagnoses. In effect, this leaves no room for the inclusion of medical discoveries. Furthermore, the limitations of ICD-9-CM results in codes being inappropriately placed throughout the book, lowering specificity and contributing to deterioration in its structure. The need for new codes that are easily accessible is great.

The CMS offers a collection of project slides that will help entities with the transition from ICD-9-CM to ICD-10-CM more clearly. Issues covered include the ICD-10 MS-DRG Conversion Project, ICD-9 code conflicts, process efficiencies and enhancements to GEMs.

Why are there now two systems (CM and PCS) instead of one?

Both systems were developed by different organizations under different timeframes. Previously, ICD-9-CM included procedural as well as clinical information. Despite being created by CMS and NCHS respectively they were referred to as one system. Similarly, ICD-10-CM and ICD-10-PCS may be referred to jointly as ICD-10-CM when implemented.

What is GEM?

GEM stands for General Equivalence Mappings. They were developed by prominent institutions in health care such as the CMS, CDC, AHIMA and the AHA. GEMs assist in converting ICD-9-CM codes to ICD-10-CM codes and vice versa. They are often referred to as crosswalks.

Who is behind the transition to ICD-10-CM/PCS?

The U.S. Department of Health and Human Services (HHS) released a final rule (HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule) requiring all entities covered by the Health Insurance Portability and Accessibility Act (HIPAA) to implement ICD-10-CM/PCS medical coding by October 1, 2013. Entities that use ICD-9 codes in claims after this date will not be paid.

How is ICD-10-CM similar to ICD-9-CM?

ICD-10-CM is based on similar guidelines and formal conventions as ICD-9-CM. It is also organized in a similar way. This means that those who are familiar with ICD-9-CM will be able to learn ICD-10-CM relatively quickly. Many chapters used in ICD-9-CM are also found in the newer edition, though sometimes they are found in a different order.

How is ICD-10-CM different from ICD-9-CM?

ICD-10-CM is an entirely new structure for diagnosis classification. The most significant structural differences are longer code length, the inclusion of more alphanumeric codes and narrative descriptions. The ICD-10-CM allows for codes to be anywhere from three to seven digits of mixed numbers and letters (beginning with a letter), while the ninth edition only allows for three to five digit codes that are mostly numeric. Another difference is that ICD-10-CM uses computer-readable tables that no longer have section header or chapter codes.

While the ninth edition has approximately 13,000 codes, the tenth has approximately 69,000. The concurrent addition of ICD-10-PCS raises this number of codes to 140,000. Part of the reason for this dramatic increase is due to the emphasis on laterality. Systems that are highly lateral see an increased number of chapters in ICD-10-CM. In fact, twenty-seven percent of the codes include “right,” while another twenty-seven percent includes “left.” These descriptions will allow for greater specification and efficiency.

How will the ICD-10-CM/PCS differences be beneficial to treatment?

Despite the daunting increase in number, ICD-10-CM can transmit greater amounts of information. One code can inform a health care worker of: a disease and its manifestation, stage of treatment (initial, follow-up, or late effects), or in obstetric care, trimester of procedure. Further, while ICD-9-CM only specifies condition, ICD-10-CM specifies location. In the lungs, for instance, the ICD-9-CM would only be able to indicate a condition of the lungs, while ICD-10-CM indicates left lung, right lung, both lungs, or unspecified. This will improve speed of diagnosis as well as treatment.

How else are the ICD-10-CM/PCS differences beneficial to healthcare providers and patients?

These more detailed codes will result in a better understanding of disease patterns as well as treatment outcomes. Such valuable information is important to the advancement of medical care. Additionally, ICD-10-CM offers several logistic improvements. For instance, the detailed information transmitted through the new code will make operational processes such as claim submissions and reimbursement more efficient. This additional detail will make initial claims clearer for payers. Furthermore, this more precise system will result in fewer unnecessary tests and ultimately will reduce administrative overhead.

How is ICD-10-PCS different from ICD-9-CM?

ICD-10-PCS is substantially different from Volume 3 of ICD-9-CM that it is replacing. It is also noticeably different from CPT ® codes that are used. It is an entirely new system that is meant to better address the quickly changing medical field and its medical procedures. Utilizing the same multi-axial design as ICD-10-CM, it also results in greater granularity. Similarly to ICD-10-CM, the code emphasizes laterality, dissimilarly; ICD-10-PCS requires it as “unspecified” is not anatomically possible.

Those using ICD-10-PCS will be required to have greater anatomical and physiological knowledge than under ICD-9-CM. This difference may require the coder to gain additional knowledge outside of their specialty areas.

How does ICD-10-PCS code work?

The first characters indicate what, where and how, while the fifth indicates approach, the sixth indicates device and the seventh includes a qualifier. Anatomy and procedure are well covered by this coding system. For instance, medical and surgical (0) action on the endocrine system (G) in the form of excision (B)of the left adrenal gland (2) via a percutaneous approach (3) carried out with no device (Z) or qualifier (Z) results in the code 0GB23ZZ. Clearly, ICD-10-PCS transmits a great deal of information through a relatively small code.

A PDF that includes some examples of ICD-10 coding tables can be found here. These useful examples demonstrate the way in which coding will be organized.

Steven J. Steindel, PhD, FACMI, further explains learning and using ICD-10-PCS in an entry on the Journal of AHIMA’s website. He provides greater insight into how coding in ICD-10-PCS works as well as its use.

What challenges will be presented by the transition to ICD-10-CM/PCS?

Equating the documentation in medical records as they correlate to ICD-10-CM/PCS definitions will be a significant challenge in transitioning to the new format. Healthcare professionals, who are already working under tight time constraints, will be asked to use an unfamiliar coding system. Many will be reluctant to make the switch in their documentation procedures unless there is a strong urge towards following through with ICD-10-CM/PCS notation. This is especially true in cases of complex procedures that may require multiple codes. In order to ensure clinical clarity and precision, healthcare providers must adhere to the new coding standard.

Will ICD-10-CM/PCS help build an electronic medical record?

Yes, both systems are tailored to be used in electronic health record systems. These more modern codes will take advantage of clinical reference terminology and are more conducive to computer-assisted coding.

How much will ICD-10-CM/PCS cost to implement?

The RAND Science and Technology Policy Institute conducted a survey on the costs and benefits of introducing the ICD-10 systems. Their study found that the new systems could save up to seven billion dollars over the next ten years.

What happens when ICD-11 is created? Why not just wait for ICD-11?

Currently, WHO is drafting an updated ICD edition for endorsement by 2015 at its World Health Assembly. The alpha draft was made available online in July 2011. Unlike previous developments, the WHO is utilizing Web 2.0 principles to construct the document via a multi-author drafting platform. There is no set implementation date, or clear timeframe. This means waiting many extra years and further additional modifications will likely be need for implementation in the United States. Furthermore, ICD-10 will be more similar to ICD-11 than ICD-9. Many of the costs that would go into upgrading directly to ICD-11 will be surpassed by first implementing ICD-10-CM/PCS.

What is HIPAA 5010?

HIPAA (the Health Insurance Portability and Accountability Act) 5010 is a replacement for the current X12 submission standard that is used for determining what entities must use for conducting electronic transactions. Such transactions are responsible for transmitting sensitive health information between specific parties. For instance, a health care provider sending medical claims to a health plan for payment via an electronic exchange must do so under a specified cryptographic standard.

Other transactions include:

  • payment
  • remittance advice
  • claims status
  • enrollment and disenrollment
  • referrals
  • authorizations

The standard is intended to protect the sensitive patient information that is transmitted. Currently, version 4010 is being used under HIPAA standards. HIPAA 5010 is equally important to the realization of ICD-10-CM/PCS, despite its lack of notoriety.

When will HIPAA 5010 be implemented?

Covered entities must have met level I compliance by January 1, 2011. This level of compliance entails the ability to process 5010 transactions for use in testing as well as transition with partners that are able.

Level II compliance is required by January 1, 2012. Covered entities must use HIPAA 5010 for all transactions at this time.

Why is HIPAA 5010 necessary and how is it different from HIPAA 4010?

HIPAA 5010 will account for the increased complexity of ICD-10-CM/PCS codes, ensuring the cryptographic protection of sensitive information sent electronically. It also operates in a distinctly different way. For instance, it includes more clearly defined situational rules that will help with specific transactions. HIPAA 500 does not necessarily require ICD-10-CM/PCS codes. It is able to differentiate between ICD-9 and ICD-10-CM/PCS, potentially clarifying issues surrounding billing due to two sets of code.

You can read more about the eleventh edition of the WHO ICD and its development online at their website.

Medical Billing and Coding Online