Oh, dear: ICD-10 is almost here

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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Wham! ICD-10!

Oct. 1, 2015. You may remember the predictions of global technological dysfunction and potential mayhem that was to be delivered by Y2K, the resetting of computer clocks at the turn of the millennium. What happened? Nothing! No global crisis appeared.

Oct. 1, 2015. A potential catastrophic failure in the U.S. system of payment for medical care by insurers is predicted by doomsayers. Why? ICD-10-CM: International Classification of Diseases, 10th Revision, Clinical Modification. As of Oct. 1, 2015 all diagnostic codes billed to insurers and/or transmitted between HIPAA covered entities must be submitted in the ICD-10-CM format. All insurers, in turn, should be fully capable of processing ICD-10-CM formatted claims. Any failure in reimbursement, therefore, would stem from either improper submission of bills or from faulty processing of the claims. Fortunately, as ICD-10 implementation was originally scheduled for 2014, the Medicare Administrative Contractors (MACs), the insurance industry, the electronic clearinghouses, billing offices, and medical care providers have been afforded an extra year to prepare for the coming of the codes.

Unlike some previous billing and coding policy modifications, which allowed for a transition period of overlapping old and new billing parameters, there will be no gradual shift from ICD-9 to ICD-10. On Sept. 30, 2015, ICD-9 diagnostic codes will be used. On Oct. 1, 2015, all diagnostic codes submitted to insurers will need to be in the ICD-10 format for processing and payment.

After Oct. 1, no play = no pay.

(There is one exception to the transition rule. Specifically, entities that are not subject to HIPAA coverage are not required to change to ICD-10 on Oct. 1. Consequently, they may or may not continue processing claims in ICD-9 format. Such organizations include workers compensation, disability, and property and casualty insurance plans. It would be best to check with the individual plans when such claims arise, in order to determine which diagnostic code sets should be used.)

Why a new diagnostic coding system when the old one seems to be working just fine? Anyone who has tried to seek out a specific ICD-9-CM code may have been surprised to see instances of seemingly unrelated dermatologic conditions lumped under one code. For example, ICD-9-CM diagnosis code 757.39 includes conditions as diverse as pseudoxanthoma elasticum, epidermolytic diseases, and porokeratoses. ICD-10-CM will provide more disease- and condition-specific diagnostic codes. More precise coding will also facilitate statistical tracking of care and treatment patterns correlated with specific diseases.

There are several steps that one may take to ensure coding success with ICD-10-CM.

  • You, the medical care provider, should become familiar with the basic ICD-10 coding parameters.
  • Ensure that chart documentation will include the following data that will facilitate optimal diagnostic coding:

o Laterality: specify whether skin neoplastic lesions are located on the left or right side, such as: left upper eyelid, right ear, left arm, etc.

o Specificity: details of causation and type of an eruption may need to be specified. For example, if an eruption is caused by a drug, that may additionally have to be identified and coded.

o Relevant comorbidities: document conditions or disorders associated with a primary disease diagnosis, as these will likely have their own ICD-10 diagnostic code.[pagebreak]

  • Be certain that your practice management program is updated to handle ICD-10 codes, claims, and billing, and will be able to produce both ICD-9 and ICD-10 formatted claims during the initial time of overlap, when claims in both formats may be submitted or appealed.
  • Electronic health records (EHR) should similarly be optimized to select proper ICD-10 diagnostic choices.
  • Train office staff to recognize relevant ICD-10 features pertinent to their functions:

o Billers, coders, and front office workers must be able to select optimal codes both for billing purposes and for eligibility verifications.

o Other office staff, such as nurses, must be trained to recognize proper ICD-10 codes for submission to insurers and pharmacies when seeking prior authorization for office visits, procedures, treatments, and medications.

  • If using an outside billing service and/or electronic clearinghouse for billing, ensure that they are fully set up to generate and accept ICD-10 claims.
  • Some insurers, such as MACs, are allowing for acknowledgement testing to be done both directly and through a billing and/or clearinghouse. Take advantage of this opportunity to run real claims through the system.
  • Similarly, test the capabilities of in-house and outsourced billing services by generating practice claims in ICD-10 format.
  • Budget appropriately for potential costs:

o Staff training time.

o Practice management software updates.

o Electronic health records program updates.

o Added staff work time for systems and billing testing.

o The possibility of delayed or improper payments following the Oct. 1 implementation date.

ICD-9-CM has 13,000 diagnosis codes, and ICD-10-CM has a little over 68,000. Scary. Not! In reality, we will be using a very small subset of the new codes. To help demystify ICD-10 coding the AAD has published an ICD-9 CM to ICD-10-CM Crosswalk for Dermatology, available for a small charge. This highly useful, laminated document lists over 400 most commonly used dermatologic codes in both ICD-9 and corresponding ICD-10 format. (Learn more about this and other AAD resources for ICD-10 at www.aad.org/ICD10.) Identify the 90 percent most common ICD-9-CM codes used in your office. Then, convert these to ICD-10 and you will see that a relatively limited number of new diagnostic codes will satisfy 90 percent of your billing requirements.

Still scared? Over the next several editions of Cracking the Code I will walk you through some common dermatology scenarios and how they will play out in ICD-10.

Example 1. In October 2015 you want to appeal a rejected claim for services rendered on Sept. 29, 2015. As ICD-10 is then being exclusively used, you consider whether ICD-10 diagnostic codes should be submitted on the appeal. However, since the billed services were in September of 2015, you appeal using the original billed ICD-9 coding.

Answer: Correct. All claims for services generated prior to Oct. 1, 2015, are to be billed utilizing the ICD-9 diagnostic codes, regardless of the date of the appeal.[pagebreak]

Example 2. In order to test Medicare’s ability to properly process ICD-10-coded claims, you decide to send in occasional real patient claims with ICD-10 diagnostic coding to your MAC prior to Oct. 1, 2015. You expect that if the claims are paid, you have coded properly.

Answer: Incorrect. All claims for services prior to Oct. 1, 2015, must be submitted with the ICD-9 diagnostic codes, or they will not be paid. However, a selection of real patient charges should be submitted with ICD-10 diagnostic codes as part of the acknowledgement testing process. These claims will not be paid by the MAC, but will generate the following acknowledgement codes, sent to the billing provider:

277CA - indicating that the claim was appropriate and accepted; or

999 - indicating that the claim was rejected.

Example 3. As test billing in the ICD-10 format seems to constitute a burden to your office, you decide to avoid the hassles of test billing with ICD-10 codes prior to Oct. 1, and will simply confidently “go live” with the new code set on Oct. 1.

Answer: Bad idea. If you find out after Oct. 1 that your billings are being rejected, you will be paid absolutely nothing. Your MAC is offering free test claim processing. Take advantage of the offer. You also need to check which of your commercial payers are currently conducting acknowledgement testing and begin participating in that process as well.

Example 4. In order to ensure that your claims are appropriately processed after Oct. 1, 2015 you submit diagnosis lines to your MAC with both ICD-9 and ICD-10 codes for the same diseases/conditions.

Answer: Incorrect. After Oct. 1, 2015, the MAC will return to the provider any claims that are coded with both ICD-9 and ICD-10 codes.

Example 5. After Oct. 1, 2015, you will continue coding with Current Procedural Terminology (CPT) for outpatient services.

Answer: Correct. CPT® procedural codes will continue to be used after Oct. 1, 2015.