On Aug. 24, 2012, Department of Health and Human Services (DHHS) Secretary Kathleen Sibelius, through 2012 ICD-10-CM final rule, announced an extension to the ICD-10-CM compliance date from Oct. 1, 2013 to Oct. 1, 2014.

This means that all ‘covered entities’ — as defined by the Health Information Portable Accountability Act (HIPAA) — are required to adopt ICD-10-CM for use in all HIPAA transactions with dates of service on or after Oct. 1, 2014. 

Read the AADA's comments to CMS on implementation of ICD-10-CM.

Below is a comprehensive article that summarizes ICD-10-CM changes and the timeline for implementation.

Getting ready for ICD-10-CM

This primer on the International Classification of Diseases Clinical Modification, 10th Revision, (ICD-10-CM) is designed to guide you through the transition that the coding system revision and related changes to electronic transactions have set in motion. It explains why the revision was necessary, descibes the similarities and differences between the two coding systems, how the ICD-10-CM is structured, and what billing system updates you must adopt to accommodate the new codes. We hope you find this primer helpful.

Please email AAD coding staff at ppm1@aad.org with any questions.

Background

In 1993, the World Health Organization (WHO) implemented ICD-10-CM to replace ICD-9-CM, the latter of which needed to be revised primarily because it was running out of category space. Based on its scientific classification, each three-digit category was limited to 10 subcategories. With the majority of numbers in most categories already assigned diagnoses, ICD-9-CM essentially ran out of numbers to accommodate future medical advances.

Additionally, it has not kept up with medical terminology and practice. On the other hand, ICD-10-CM represents a significant improvement over ICD-9-CM. Some attributes that have been added to ICD-10-CM (U.S. version of WHO ICD-10-CM) include expanded distinctions for managed care encounters, requested expansion in levels of specificity to address research, quality measurement, public health, and reimbursement purposes. Currently, ICD-10-CM is being used in nearly every country in the world except the United States.

On Jan. 16, 2009, the U.S. Department of Health and Human Services (HHS) mandated that everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) must implement ICD-10-CM for medical coding by Oct. 1, 2013. However, implementation of ICD-10-CM has now been pushed back to Oct. 1, 2014.  Dermatology practices are encouraged to take advantage of the extended compliance deadline to revise individual ICD-10-CM implementation timelines.

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Similarities between the two systems

Overall, ICD-9-CM and ICD-10-CM are similar in format with regard to guidelines, coding conventions, and rules. ICD-10-CM has an alphabetic index and a tabular list, both of which resemble those in ICD-9-CM. Maintaining the same indented format for both of these lists makes referencing easier. The alphabetic index is an alphabetical listing of terms and their corresponding code. The tabular list is a chronological list of codes based on body system or condition. The tabular list contains categories, subcategories, codes, and descriptors arranged in a numeric hierarchical structure, just like it was in the ICD-9-CM.

Additionally, many conventions have the same meaning in the ICD-10-CM as they did in the ICD-9-CM. For example, abbreviations, punctuation, symbols, and notes such as “code first,” “excludes,” "includes,” and “use additional code” have the same meaning.

Differences between the two systems

The differences between ICD-9-CM and ICD-10-CM are mostly in the organization, code composition and level of detail and specificity. Changes include revisions of chapter titles and categories, re-grouping of diseases and some modification to coding rules.

Regarding organizational changes, the Table of Drugs and Chemicals, as well as the Neoplasm Table, are located in the Index to Diseases and Injury in the ICD-10-CM. The Index to External Causes of Morbidity has also been added (V01-Y99).

The ‘V’ codes, which describe factors influencing health status and contact with health services, and ‘E’ codes, which describe external causes of injuries, poisonings and adverse effects — both of which were supplements in the ICD-9-CM — are now separate chapters in the ICD-10-CM (Z00-Z99 and S00-T88). Injuries are grouped by anatomical site in the ICD-10-CM rather than by type of injury as they were in ICD-9-CM. Some code definitions also have been revised.

In addition to gaining four chapters in the ICD-10-CM, some of the chapter titles have been revised. Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the reclassification of certain diseases and disorders.

For example, the title of Chapter 1 in the ICD-10-CM is “Certain Infectious and Parasitic Diseases,” (A00-B99), which was changed from “Infectious and Parasitic Diseases” (codes 001-139) in the ICD-9-CM. The word “certain” stresses the fact that localized infections are classified in the pertinent body system (e.g., infection of the skin and subcutaneous tissue is in chapter 12).

Some chapters were restructured to accommodate the regrouping of diseases. Chapter 12, titled “Diseases of the Skin and Subcutaneous Tissue,” was expanded from three sub-chapters in the ICD-9-CM to nine categories in ICD-10-CM. Diseases were either grouped in their own category or new categories were identified for specific disease types.

Some conditions have been reassigned to different chapters to reflect current medical knowledge. As an example, diseases and conditions of sense organs (eyes and ears) that were in the nervous system section of ICD-9-CM now have their own chapters: Chapters 7 and 8 respectively.

The most significant difference between the two coding systems is that there is a five-fold increase in the number of diagnostic codes in ICD-10-CM. More than 68,000 ICD-10-CM codes exist compared with about 14,000 ICD-9-CM codes. The additional diagnostic codes account for the enhanced level of detail and specificity in ICD-10-CM.

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The ICD-10-CM diagnosis codes consist of three to seven alpha and numeric characters (alpha characters are not case sensitive) compared with three to five digits in the ICD-9-CM. The first digit is an alphabetical letter. All of the letters in the alphabet are used except ‘U’, which has been reserved for newly discovered diseases or unknown etiology. The second digit is a numeral. All ICD-10-CM codes contain full code titles. (See ICD-9-CM and ICD-10-CM formats, below.)

ICD-9-CM format:

1  7  3             3  x
Category       Etiology, anatomical site, manifestation

ICD-10-CM format:

C  4  4            3  0x  x
Category       Etiology, anatomical site, extension, and severity

Example: 

ICD-9-CM
173.3x Other and unspecified malignant neoplasm of skin of other and unspecified parts of face
Cheeks, external forehead
Chin nose, external
Eyebrow temple

ICD-10-CM
C44  Other malignant neoplasm of skin
Includes: Malignant neoplasm of sebaceous glands
Excludes: Kaposi’s sarcoma of skin (C46.0)
                malignant melanoma of skin (C43.x)
                malignant neoplasm of skin of genital organs (C51 – C52,
                C60.x, C63.2)
Merkel cell carcinoma (C4a.x)

C44.3 Malignant neoplasm of skin of other and unspecified parts of face

C44.300 Malignant neoplasm of skin of unspecified part of face
C44.301 Malignant neoplasm of skin of nose
C44.309 Malignant neoplasm of skin of other parts of face

The injury codes (chapter 19) have been expanded so that the fifth digit defines type of injury, the sixth digit defines laterality (side of the body affected) and the seventh digit defines the encounter. The latter digit may classify an initial encounter, a subsequent encounter or sequelae.

Example:
S90.x Superficial Injury of ankle, foot, toes
The appropriate seventh character is to be added to each code from category S90.

‘A’ for an initial encounter
‘D’ for a subsequent encounter
‘S’ for sequela

     S90.0 Contusion of ankle
S90.01x Contusion of right ankle

Some ICD-10-CM codes may have an ‘x’ as the fourth or sixth digit. The ‘x’ serves as a placeholder to save space for future expansion that will enable users to code more accurately.

For example, there may be a six-digit code for which there is presently no fifth digit sub-classification. Therefore, an ‘x’ is used as the fifth digit.

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New features in ICD-10-CM

The ICD-10-CM has some new features that allow for a greater level of specificity and clinical detail that correlate with current medical terminology. Those relevant to dermatology are as follows:/p>

Laterality refers to the side of the body affected, such as right, left, or bilateral. This code requires dermatology coding personnel to specify the location of disease.

Example:
S60.56 Insect bite (nonvenomous) of hand
              S60.561 Insect bite (nonvenomous) of right hand
              S60.562 Insect bite (nonvenomous) of left hand

Combination codes for certain conditions and common associated symptoms and manifestations will have two or more conditions/symptoms or etiology/manifestations assigned to one code instead of the multiple codes required in ICD-9-CM classification.

Example:
L57 Skin changes due to chronic exposure to nonionizing radiation
        Use additional code to identify the source of the ultraviolet radiation
        (W89, X32)

L57.0 Actinic keratosis
           Keratosis NOS
           Senile keratosis
           Solar keratosis

X32 Exposure to sunlight
        Excludes 1: Radiation-related disorders of the skin and
        subcutaneous tissue (L55 – L59)
        Man-made radiation (tanning bed) (W89)

Similarly, the ICD-10-CM includes combination codes for poisonings and their associated external causes.

Example:
T36.7x1 Poisoning by antifungal antibiotics, systematically used, accidental (unintentional)

Excludes notes: The ICD-10-CM contains two types of “excludes” notes that are clearly distinguished to eliminate any confusion about the meaning of the exclusion.

Excludes 1: Indicates that the code excluded should never be used with the code where the note is located (do not report both codes).

Excludes 2: Indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time, in which case both codes may be assigned together (both codes can be reported to capture both conditions).

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Tips on using ICD-10-CM codes

As with the ICD-9-CM, proper and accurate coding requires the use of the ICD-10-CM Official Guidelines for Coding and Reporting publication that contains information about the coding convention. Because the alphabetic index and tabular list are similar in both systems, the same method can be used to look up codes, meaning you can look up the diagnostic terms in the alphabetic index and then verify the code number in the tabular list.

Coding professionals recommend that training take place about six months prior to the Oct. 1, 2014
compliance date.

Dermatology practices mostly will be using Chapter 2 of the ICD-10-CM, which contains codes for most benign and all malignant neoplasms (C00-D49). However, coding personnel should not restrict their search to this section because the appropriate diagnosis may be found in another chapter. It is important for coders to begin their search in the alphabetic index before choosing the appropriate code in the tabular section.

Note that the additional digits in the ICD-10-CM codes offer more detailed and specific documentation. As a result, health insurance payers will demand more specificity for claims being submitted for reimbursement. The transition from ICD-9-CM to ICD-10-CM coding will require significant changes in the dermatologists’ documentation in the medical record, workflow, and technology to support ICD-10-CM coding.

For example, contact dermatitis in the alpha index can be coded in one of three ways, as follows:

L23 Allergic contact dermatitis; or
L23.3 Allergic contact dermatitis due to drugs in contact with skin; or
L23.81 Contact dermatitis due to animal (cat) (dog) dander.

The ICD-10-CM code that most closely reflects the cause of the disease should be chosen. However, there will still be some non-specific codes (“unspecified” or “not otherwise specified”) for use when detailed documentation to support a more specific code is unavailable. Remember, codes are considered invalid if they are missing an applicable character.

Even though the coding systems are similar, ICD-10-CM codes have been updated to reflect modern medicine and current medical terminology. Consequently, coding personnel may benefit from obtaining knowledge of advanced anatomy and physiology to have a basic understanding of the ICD-10-CM coding system.

There will be a period when dermatology office coding systems will need to access both sets of codes for a period of up to two years as the country transitions from one code set to the other one. Bear in mind that the code selection will be date-of-service driven, e.g., services provided on Sept. 30, 2014 will be reported with ICD-9-CM codes (even if the claim is submitted on Oct. 1, 2014). Services provided on Oct. 1, 2014, will be reported with ICD-10-CM codes only.

To that end, the Centers for Medicare and Medicaid Services (CMS) has developed the General Equivalence Mappings (GEMs), a crosswalk tool for all providers. Designed to serve as a link between the coding sets, the GEMs can help dermatology office personnel in converting systems, applications, reports, and documents.

However, dermatologists may want to hold off on offering training for the new coding system because the ICD-10-CM codes are still changing and will not be frozen until Oct. 1, 2013. Additionally, the ICD-10-CM codes will not be implemented until Oct. 1, 2014. Getting up to date with diagnosis codes that may change through next fall and won’t take effect until fall 2014 may be confusing for staff who still have to work with ICD-9-CM. Coding professionals recommend that training take place about six months prior to the Oct. 1, 2014 compliance date.

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Benefits of ICD-10-CM

ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM, according to the CMS. In addition to updating the terminology and disease classification to be consistent with current clinical practice, the new classification system is expected to provide much better data needed for the following activities:

• Measuring the quality, safety and efficacy of care;
• Reducing the need for attachments to explain the patient’s condition;
• Designing payment systems and processing claims for reimbursement;
• Conducting research, epidemiological studies and clinical trials;
• Setting health policy;
• Conducting operational and strategic planning;
• Designing health care delivery systems;
• Monitoring resource utilization;
• Improving clinical, financial and administrative performance;
• Preventing and detecting health care fraud and abuse; and
• Tracking public health and risks.

When the medical record documentation does not support a more specific code, ICD-10-CM has maintained non-specific codes that can be used.

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Related resources:

• General information about ICD-10-CM from CMS.
• Find the latest updates on ICD-10-CM files, including downloads of the ICD-10-CM index, tabular list, and guidelines.
• A crosswalk through Chapter 12.
• "Coding changes on the horizon," in the June 2011 issue of Dermatology World.
• ICD-10 tips.
• ICD-10 FAQs.
• Learn more about how you can participate in the development of ICD-11.