Are you prepared for the transition to the International Classification of Diseases, 10th Revision (ICD-10)? Health care providers throughout the U.S. currently use ICD-9, whereas health care providers in the rest of the world use ICD-10. In 2009, the U.S. Department of Health and Human Services published a regulation requiring U.S. providers to transition to ICD-10; the latest compliance date for the transition has been set for October 1, 2015. Although Congress has intervened and delayed previous deadlines, it is unlikely to give providers another extension.
The American College of Surgeons (ACS) encourages members to become familiar with the new code sets, to understand the differences between ICD-9 and ICD-10, and to prepare for how the change may affect day-to-day practice management. Indeed, the effect on billing processes could be profound because the transition expands the selection of diagnosis codes from a small pool to nearly 68,000.1
What is the ICD?
The Health Insurance Portability and Accountability Act (HIPAA) identified ICD-9 clinical modification (ICD-9-CM) as the standard code set for reporting diagnoses and inpatient procedures in 2003. ICD is a diagnostic tool for epidemiology, health management, and clinical purposes, which offers a systematic recoding, analysis, interpretation, and comparison of mortality and morbidity data collected in different countries. It also is used to monitor the incidence and prevalence of diseases and other health care problems around the world.
Currently, ICD-9-CM includes both diagnosis and procedural codes. Similar to ICD-9, ICD-10 comprises two categories of code sets. The first is ICD-10-CM, which providers will use in both the inpatient and outpatient setting to report diagnoses. The second is the ICD-10 procedure coding system (ICD-10-PCS), which will be used only to code for hospital inpatient procedures.2
What will ICD-10 identify?
The ICD-10 code set reflects advances in medicine and uses current medical terminology. The code format is expanded, which means that providers will be able to include greater detail within the code to provide more specific information about the diagnosis. The flexibility of the ICD-10 code set allows for expanding and including new technologies and diagnoses. It also encompasses additional information about injuries and ambulatory and managed care. ICD-10 will combine diagnosis and symptom codes to better define certain conditions, increase specificity through greater code length for identification of disease processes to aid in research, and provide the ability to specify laterality. The College urges Fellows to begin preparing now, as the change is expected to be disruptive.
Is it necessary to upgrade to ICD-10?
Yes—the conversion to ICD-10 is a HIPAA code-set requirement. Providers, including physicians, are HIPAA “covered entities,” which means that they must comply with HIPAA requirements. In addition, conversion to ICD-10 is mandatory in order for providers to receive payment for the services they render. A failure to convert to ICD-10 will negatively affect payment. Although HIPAA code-set requirements only apply to HIPAA electronic transactions, it would be too burdensome on the health care industry to use ICD-10 in electronic transactions and ICD-9 in manual transactions. Payors are expected to require ICD-10 codes to be used in other transactions, such as on paper, through a dedicated fax machine, or via the phone.2 The bottom line is that hospitals and third-party payors should be ready for ICD-10, so surgeons and other health care professionals should be as well.
How does the transition to ICD-10 affect hospital-employed surgeons?
The transition will affect hospital-employed surgeons very similarly to private practice surgeons. Although employed surgeons will be able to rely on their institutions or health systems to train their staff, they will still need to provide their billing and coding staff with the documentation and paperwork necessary to accurately code claims using ICD-10.
What are some specific differences between ICD-9-CM and ICD-10-CM?
The differences between the ICD-9-CM and ICD-10-CM code sets may not be immediately evident. Table 1 below provides an overview of characteristics with which to become familiar while transitioning to ICD-10-CM. The expanded code format of ICD-10-CM means that coders will have the ability to include greater details within the code, and greater detail means that the code can provide more specific information about the diagnosis.
Table 1. Differences between ICD-9-CM and ICD-10-CM code sets
|3 to 5 characters in length||3 to 7 characters in length|
|Approximately 13,000 codes||Approximately 68,000 current codes|
|First character may be alpha (E or V) or numeric; characters 2–5 are numeric||Character 1 is alpha; characters 2 and 3 are numeric; characters 4–7 are alpha or numeric|
|Limited space for new codes||New codes can be added|
|Limited code detail||Specific code detail|
|No laterality||Includes laterality|
Will ICD-10-CM replace Current Procedural Terminology (CPT)* coding?
No, the implementation of ICD-10-CM does not affect CPT coding for outpatient procedures. ICD-10-PCS codes are for hospital inpatient procedures only. Surgeons’ offices and hospitals will continue to use CPT codes to report services and procedures in outpatient and office settings. However, most surgeons will have to be familiar with both CPT and ICD-10-CM codes to be paid, and with ICD-10-PCS for the hospital to be reimbursed for inpatient procedures. Hospital coders often ask for clarification of documentation, as most surgeons know. Familiarity with ICD-10 will make this experience much less burdensome.
Is ICD-10 currently being updated?
A code freeze has been placed on both the ICD-9 and ICD-10 code sets while the transition to ICD-10 occurs. The code freeze will end when implementation of ICD-10 takes effect October 1, 2015. Regular updates to ICD-10 will begin on October 1, 2016. No updates have been made to ICD-9 since October 1, 2013, as the code set is no longer being maintained.
The ICD-10 Coordination and Maintenance Committee, the Centers for Medicare & Medicaid Services (CMS) committee responsible for approving code changes to the ICD, has continued to meet twice a year during the freeze. At these meetings, the public is allowed to comment on whether new diagnosis and procedure codes should be created in order to capture new technology or disease. New code requests will be evaluated for implementation in ICD-10 on or after October 1, 2016.3 The ACS has representation every step of the way and is already working to improve ICD-10.
What steps should I take to begin implementing ICD-10 in my practice?
The implementation of ICD-10 will require coordination of multiple aspects of a surgical practice. An important first step in the ICD-10 implementation process is to conduct a practice impact assessment, which will be useful in bringing awareness to the areas of the practice that will be most affected by the transition to ICD-10. It includes an analysis of how the practice will accept, process, and translate coded data under the ICD-10 system. An impact assessment may evaluate how ICD-10 will affect the following aspects of your practice:
- Systems and vendor contracts: Ensure vendors can accommodate ICD-10 needs and find out how and when the vendor plans to update existing systems; review new and existing vendor contracts and evaluate vendor offerings and capabilities against the organization’s expectations
- Business practices: Once ICD-10 is implemented, determine how the new codes will affect processes for referrals, authorizations/pre-certifications, patient intake, physician orders, and patient encounters
- Productivity: Train staff to accommodate the substantial increase and specificity in code sets, physician workflow and patient volume changes, and the amount of time needed for testing
- Reimbursement structures: Coordinate with payors on contract negotiations and new policies that reflect the expanded code sets
What resources are available to aid in this transition?
The ACS has developed an ICD-9-CM to ICD-10-CM crosswalk of the most frequently reported general surgery diagnosis codes to assist surgeons with the transition to ICD-10. Table 2, below, can help determine how a particular ICD-9 code will translate to ICD-10.
The crosswalk was published in the February issue of the Bulletin.4 Surgeons should continue to monitor the ACS ICD-10 website leading up to the October 1 implementation date for more ICD-9-to-ICD-10 coding examples and other important information. Additional ICD-10 resources are located in the sidebar above.
While ICD-10 may seem more burdensome than ICD-9, the system has its benefits. It will be more specific, more compatible with electronic health record systems, and will help clarify the true diagnosis for the surgical patient.
Table 2. ICD-10 Crosswalk for General Surgery
This crosswalk has been developed by the ACS and may be used as a basic guide for comparing a selection of frequently reported general surgery procedures between ICD-9 and ICD-10. Note that accurate coding is the responsibility of the provider. This crosswalk is intended only as a resource to assist in the billing process.
|ICD-9 (non-specified)||ICD-9||ICD-9 description||ICD-10||ICD-10 description|
|569–Other disorders of the intestine||569.0||Anal and rectal polyp||K62.0||Anal polyp|
|569.1||Rectal prolapse||K62.2||Anal prolapse|
|569.2||Stenosis of rectum and anus||K62.4||Stenosis of anus and rectum|
|569.3||Hemorrhage of anus and rectum||K62.5||Hemorrhage of anus and rectum|
|569.4||Other specified disorders of the rectum and anus|
|569.41||Ulcer of anus and rectum||K62.6||Ulcer of anus and rectum|
|569.42||Anal or rectal pain||K62.89||Other specified diseases of anus and rectum|
|569.43||Anal sphincter tear (healed) (old)||K62.81||Anal sphincter tear (healed) (nontraumatic) (old)|
|569.44||Dysplasia of anus||K62.42||Dysplasia of anus|
|569.49||Other||K62.49||Other specified diseases of anus and rectum|
|569.5||Abscess of intestine||K63.0||Abscess of intestine|
|569.6||Colostomy and enterostomy complications|
|569.60||Colostomy and enterostomy complications, unspecified||K94.00||Colostomy complication, unspecified|
|K94.10||Enterostomy complication, unspecified|
|569.61||Infection of colostomy or enterostomy||K94.02||Colostomy infection|
|569.62||Mechanical complication of colostomy and enterostomy||K94.03||Colostomy malfunction|
|569.69||Other complications||K94.09||Other complications of colostomy|
|K94.19||Other complications of enterostomy|
|569.7||Complications of intestinal pouch|
|569.79||Other complications of intestinal pouch||K91.858||Other complications of intestinal pouch|
|553–Other hernia of abdominal cavity without mention of obstruction or gangrene||553.0||Femoral hernia|
|553.00||Unilateral or unspecified (not specific as recurrent)||K41.90||Unilateral femoral hernia, without obstruction or gangrene, not specified as recurrent|
|553.01||Unilateral or unspecified, recurrent||K41.91||Unilateral femoral hernia, without obstruction or gangrene, recurrent|
|553.02||Bilateral (not specified as recurrent)||K41.20||Bilateral femoral hernia, without obstruction or gangrene, not specified as recurrent|
|553.03||Bilateral, recurrent||K41.21||Bilateral femoral hernia, without obstruction or gangrene, recurrent|
|553.1||Umbilical hernia||K42.9||Umbilical hernia without obstruction or gangrene|
|553.20||Ventral (unspecified)||K43.9||Ventral hernia without obstruction or gangrene|
|553.21||Incisional||K43.2||Incisional hernia without obstruction or gangrene|
|553.29||Other||K43.9||Ventral hernia without obstruction or gangrene|
|K46.9||Unspecified abdominal hernia without obstruction or gangrene|
|553.3||Diaphragmatic hernia||K44.9||Diaphragmatic hernia without obstruction or gangrene|
|459–Other disorders of the circulatory system||459.1||Postphlebitic syndrome|
|459.10||Postphlebitic syndrome without complications||I87.009||Postthrombotic syndrome without complications of unspecified extremity|
|459.11||Postphlebitic syndrome with ulcer||I87.019||Postthrombotic syndrome with ulcer of unspecified lower extremity|
|459.12||Postphlebitic syndrome with inflammation||I87.029||Postthrombotic syndrome with inflammation of unspecified lower extremity|
|459.13||Postphlebitic syndrome with ulcer and inflammation||I87.039||Postthrombotic syndrome with ulcer and inflammation of unspecified lower extremity|
|459.19||Postphlebitic syndrome with other complications||I87.039||Postthrombotic syndrome with ulcer and inflammation of unspecified lower extremity|
Editor’s note: Accurate coding is the responsibility of the provider. This article is intended only as a resource to assist in the billing process.
*All specific references to CPT codes and descriptions are © 2014 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.
- American Medical Association, ICD-10 code set to replace ICD-9. Background. Available at: www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page. Accessed April 22, 2015.
- American Medical Association, ICD-10 code set to replace ICD-9. FAQs. Available at: www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page. Accessed April 22, 2015.
- American Medical Association, ICD-10 code set to replace ICD-9. ICD-9 and ICD-10 code freeze. Available at: www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page. Accessed April 22, 2015.
- Gokak S. ACS develops ICD-9 to ICD-10 crosswalk to assist in billing. Bull Am Coll Surg. 2015;100(2):31-35.