If you do any insurance billing for services performed in your practice, you are probably aware that as of October 1, 2015, there was a major change in the codes used by health-care providers to identify diagnoses.
It is your responsibility to know and use the new ICD-10 codes in your insurance billing; otherwise, you won’t be reimbursed for the services you provide to your clients.
Let’s dive right into the details of what an ICD-10 code is and how it will affect your billing.
Transition Time
The International Classification of Diseases (ICD) is a standard diagnostic coding system implemented by the World Health Organization (WHO). ICD-10 is the 10th Revision, Clinical Modification (ICD-10-CM) and replaces the International Classification of Diseases, 9th Revision (ICD-9, which was developed by WHO in the 1970s).
You must now submit claims using ICD-10 codes for any services provided on or after October 1, 2015. ICD-9 codes on claims with dates of service (DOS)/dates of discharge (DOD) before the October 1 compliance date will be accepted. ICD-9 codes on claims with DOS or DOD on or after the October 1 compliance date will not be accepted. Therefore, you must use the ICD-10 codes for DOS or DOD after the October 1 compliance date.
If you have dates of service to bill that cover both before and after the change date, it is recommended you split your claim (bill) into separate bills, using the ICD-9 codes for dates of service prior to October 1 and use ICD-10 codes for after October 1. When, and if, you resubmit a claim, use the codes that were/are valid for the specific date of service.
ICD codes are different from Current Procedural Terminology (CPT) codes. ICD codes are used by prescribing physicians and other health-care providers to define the specific patient diagnosis. ICD‐10 does not replace CPT codes, which are used for billing. The transition to ICD-10 does not affect your use of CPT coding, as long as you are providing outpatient procedures. ICD-10-PCS codes are for billing hospital inpatient procedures only.
Why the Change?
The WHO changed and added additional codes to enable physicians to be more specific on claim forms in reporting the diagnosis and care provided to patients, as well as to better track the conditions, injuries, and diseases with which patients present for documentation purposes.
We all know we can’t diagnose our clients’ conditions, so if you are working with a client who was referred to you by a health-care provider, the recommended way to get an ICD-9 translation into a new ICD-10 code is to contact the referring physician directly.
Please be aware that ICD-10 has 141,000 codes—more than eight times the 17,000 codes in ICD-9—therefore, interpretation of the old ICD-9 must be accurate or it will delay or negate your ability to get reimbursed. The code you use must match the code the physician submits.
Getting Started
To get you started understanding the new system, one of the most common conditions we provide therapy for is sciatica, which used to be ICD-9 724.3. You’ll see in the table below how the code has been changed to be much more specific using the ICD-10 code, which is determined by the health-care provider. You can see how the new codes for sciatica start with M5, which indicates diseases of the musculoskeletal system and connective tissue (M00-M99), which is a Chapter Name, followed by a Block Code, followed by a Block Name.
Muscle spasm was ICD-9 728.85; it is now ICD-10 M62 and must be site-specific, not only right or left, but also to the area of the body where the spasm is occurring. Again, the ICD-10 code must be diagnosed by the referring physician. The numbers that complete the code are added once the specifics are determined.
Migraines (ICD-9 346 Diagnosis) are another common condition we treat. In the old system, there were variations in the diagnostic codes for patients diagnosed with migraines, but now it’s even more complicated. Variables include: with or without aura, chronic or acute, with or without cerebral infarction, and so on. The new ICD-10 Diagnosis code is G43, with the rest of the code based on the specifics.
Serious Specificity
There are a lot of jokes going around poking fun at the specificity of these new codes. To lighten this article up a bit, how about the new ICD-10 code for being struck by a macaw? This next one makes people laugh, too: “V97.33XD: Sucked into jet engine, subsequent encounter.” That means the patient got sucked into a jet engine more than once! Or how about “W55.41XA: Bitten by pig, initial encounter”? I know this makes sense to document farm mishaps, but still … living in the big city of San Francisco, it seems pretty unlikely to happen. And then we have “Y93.D1: Accident while knitting or crocheting.” So, while they’re amusing, it is important to know what the referring primary-care provider is diagnosing, so you know what you’ll be providing therapy for.
If you have trouble understanding all of this, you’ll find comfort in knowing you are not alone. Although health-care providers and business consultants like myself have known for years this change was coming, many people are still scrambling to be compliant. Even adjustors and bill review companies have to learn this new system. Be prepared for backlogs and payment delays, misrepresented denials, and a host of other confusions as we all work out the details and the dust begins to settle.
Irene Diamond, RT, consults with many of the most successful wellness providers, helping them double their client base and generate more repeat and referral business. Creator of the rehabilitation technique Active Myofascial Therapy—The Diamond Method and founder of Dream Practice Mastery Academy, Diamond is a 2013 Massage Therapy Hall of Fame inductee. For more information, visit www.irenediamond.com.
Resources
Medical Economics. “ICD-10 Documentation: The Key to Getting Paid.” Accessed December 2015.
http://medicaleconomics.modernmedicine.com/managed-healthcare-executive/news/icd-10-
documentation-key-getting-paid.
US Centers for Disease Control and Prevention. “International Classification of Diseases, (ICD-10-CM/PCS) Transition—Background.” Accessed December 2015. www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm.
US Centers for Disease Control and Prevention. “International Classification of Diseases, 10th Revision, Clinical Modification (ICD-1-0CM).” Accessed December 2015. www.cdc.gov/nchs/icd/icd10cm.htm#icd2014.
World Health Organization. “International Classification of Diseases.” Accessed December 2015.
www.who.int/classifications/icd/en/.