ICD-10

» Introduction to ICD-10: A Guide for Providers

Centers for Medicare

& Medicaid Services

 Compliance Date: October 1, 2015

TABLE OF CONTENTS

What is ICD-10?
Why ICD-10 matters
Why transition to ICD-10
Getting ready for ICD-10
CMS resources

This guide is intended to provide health care professionals with an overview of ICD-10. Hyperlinks to the CMS 2
website are included in the guide to direct you to more information and resources.

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 What is ICD-10?

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 What is ICD-10?

In 1990, the World Health Organization (WHO) approved the 10th Revision of the International

Classification of Diseases (ICD), known as ICD-10.

What Why When

•  A method of coding: •  ICD-10-CM and PCS are •  Compliance Date: 10/1/15
»  The patient’s state of complete revisions of their U.S. »  Outpatient services are
health and developed ICD-9 counterparts, based on the Date of
»  Institutional procedures which were adopted in 1979 Service
•  In the U.S., ICD-10 includes: »  More information per code »  Inpatient services are
»  ICD-10-CM : clinical »  Better support for care based on the Date of
modification of WHO management, quality Discharge
standard for diagnoses that measurement, and analytics
is maintained by NCHS and »  Improved ability to
is for specific use in the understand risk and severity
U.S.
»  ICD-10-PCS: inpatient Who
procedures developed and •  All HIPAA-covered entities
maintained by CMS must use ICD-10

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Why ICD-10 Matters

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Why ICD-10 Matters

ICD-10 replaces the ICD-9 code sets and includes updated medical
terminology and classification of diseases

ICD-10 CM/PCS consists of two parts:

  ICD-10-CM for diagnosis coding in all health care settings
  ICD-10-PCS for inpatient procedure coding in hospital settings

CPT coding for outpatient and office procedures is not

affected by the ICD-10 transition

WHAT IS ICD-10? WHY ICD-10

WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS
MATTERS ICD-10 ICD-10
 Why ICD-10 Matters

ICD-10-CM replaces ICD-9-CM for

diagnosis coding:
•  ICD-9-CM diagnosis codes = 3 to 5 digits
•  ICD-10-CM codes = 3 to 7 digits
•  Overall format of ICD-10 diagnosis codes similar to ICD-9

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Why ICD-10 Matters

ICD-10-PCS replaces ICD-9-CM for inpatient

procedure coding:
•  ICD-9-CM procedure codes = 3 to 4 numeric digits
•  ICD-10-PCS codes = 7 alphanumeric digits
•  ICD-10-PCS code format substantially different from ICD-9
•  Unlike ICD-9, ICD-10 expands details for many conditions

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Why Transition to ICD-10

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Why Transition to ICD-10

Better reflects current medical practice

Captures more specific data from clinical

documentation than ICD-9
•   ICD-10-CM: For fractures, for example, captures left vs. right side of
body, initial vs. subsequent encounter, routine vs. delayed healing, and
nonunion vs. malunion
•   ICD-10-PCS: Provides detailed information on procedures and
distinct codes for all types of devices

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MATTERS ICD-10 ICD-10
 Why Transition to ICD-10

Detail captured by ICD-10 can:

•   Facilitate patient care coordination across settings
•   Improve public health reporting and tracking

ICD-10 structure accommodates new codes

•   ICD-9 is running out of capacity and cannot continue to

accommodate addition of codes to reflect new diagnoses
and procedures

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Compliance Date

By October 1, 2015, your practice must start using

ICD-10 codes for services provided on or after
October 1, 2015

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Monitor Your Progress

Monitor your progress against your ICD-10

project plan, which should identify:
•  Each task to be completed
•  When tasks should begin and end
•  Who is responsible for each task

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 Getting Ready for ICD-10:
Check Your Plan

Check that your ICD-10 project plan:

•   Ensures senior leadership understands breadth and significance
of ICD-10 change
•   Assigns overall responsibility and decision-making authority for
managing the transition
•   Includes a comprehensive, realistic budget
•   Ensures involvement of all stakeholders, ranging from physicians
to clearinghouses and software vendors

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 Getting Ready for ICD-10:
Check Your Plan

Check that your ICD-10 project plan also covers:

•  Software/hardware testing
•  Staff training and sharing best practices
•  Updating internal policies to support the transition
•  Adhering to a well-defined timeline

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 Getting Ready for ICD-10:
Key Steps

Essential tasks to cover in project plan:

•   Identify commonly used ICD-9 codes and explore related ICD-10
codes
•   Identify paper and electronic forms to accommodate the ICD-10
code structure
•   Schedule ICD-10 training for clinicians, office managers, billers,
coders, and other key staff

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 Getting Ready for ICD-10:
Analyze How You Use Codes

Identify how ICD-10 will affect your practice,

specifically use of codes for:
•  Billing and submitting claims
•  Other functions, like eligibility queries, registration, and referrals

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 Getting Ready for ICD-10:
Questions for Your Analysis

Questions to inform your analysis:

•   Will I be able to submit claims?
•   You will need a billing system that is compliant with

HIPAA Version 5010 transaction standards

•   Verify that your existing billing system can submit and receive
ICD-10 codes
•   How does ICD-10 work with my EHR systems?
•   Verify whether your EHR captures ICD-10 codes as needed for
billing purposes

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 Getting Ready for ICD-10:
Questions for Your Analysis

How do I become familiar with ICD-10 codes?

•   Obtain ICD-10 code books if you use ICD-9 books for code
look-up
•   Compare ICD-9 codes commonly used in your office to
corresponding ICD-10 codes
•   Check your software for an ICD-10 look up function
•   Acquire ICD-10 code training
•   Obtain new ICD-10 forms if you use ICD-9 forms today

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 Getting Ready for ICD-10:
Look for Efficiencies

Consider opportunities to make coding

more efficient:
•   List your most commonly used ICD-9 codes and look at the
ICD-10 codes you will use in their place
•   Then think about how front-office staff can help capture new
information required under ICD-10 (e.g., trimester of pregnancy
for obstetric coding)

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Changes to Your Practice

Identify changes you might need to make

Look at:
•   Business processes
•   Clinical documentation
•   Practice management and clinical software
•   Readiness of your vendors (e.g., practice management, billing, and
clearinghouse products and services)

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 Getting Ready for ICD-10:
Business Processes
Business processes to consider include:
•   Referrals
•   Authorization/precertification
•   Patient registration and scheduling
•   Physician orders
•   Contracts with payers, clearinghouses, and other business
partners
•   Financial operations
•   Public health reporting

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 Getting Ready for ICD-10:
Documentation

Clinical documentation of key medical

concepts is essential to selecting specific
ICD-10 codes.

As part of patient care, clinicians already document most

concepts needed for ICD-10 coding.

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Documentation

Does your practice’s documentation capture

necessary detail?
•   Use documentation from recent patient encounters to try
selecting ICD-10 codes
•   Note any changes needed to documentation for ICD-10 coding

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Communication

Confirm ICD-10 plans and readiness of your:

VENDORS
Software/systems PAYERS
Clearinghouses
Billing services

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Talk with Payers
•   Ask payers if they are revising
contracts or policies based on
ICD-10; if so, negotiate new
contracts
•  Ask about testing plans

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Talk with Clearinghouses and Billing Services

If you work with a clearinghouse or billing service, check on

their ICD-10 preparation and readiness

Figure out how you can work together so your

claims can be processed using ICD-10
•  Note: Clearinghouses cannot help identify which ICD-10 codes
to use unless they offer coding services

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Talk with Software/Systems Vendors
Talk to your EHR and/or practice
management system vendors to see
when they plan to upgrade your system
for ICD-10

Vendors will need to have products

ready as soon as possible so you can
test them; if they don’t, you may need
to find a new vendor who has ICD-10­
ready products

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Vendor Evaluation

•   Identify your current vendors

•   Contact vendors to confirm they are
ICD-10-ready and how they will help
you get ready
•   Assess whether you want or need to
develop new vendor relationships
•   Evaluate your current vendor or new
vendor by asking key questions

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 Getting Ready for ICD-10:
Key Vendor Questions

Ask your vendors:

•   Will you install products well before the October 1, 2015,
compliance date, so I can begin testing?
•   Will you support my products after October 1, 2015?
•   Will you update my products and applications for ICD-10?
•   Will you keep my products updated? Will there be a charge?
•   Will I need new hardware to accommodate ICD-10-related
software changes?

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 Getting Ready for ICD-10:
Key Vendor Questions

More questions for your vendors:

•  What costs are involved with maintaining new products?
•  Will you offer product support for the transition? If so, for
how long?
•  How do I report issues and how quickly will you respond?
•  Will you provide training on your software?
•  Will you offer support during internal ICD-10 testing?
•  Will you help me test my system with payers and other
trading partners?

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 Getting Ready for ICD-10:
Testing

Once your system is ICD-10-ready, test it

•   Try systems that send and receive codes to ensure they process
ICD-10 codes correctly

•   Test transactions that affect your practice most, such as:

•   Claims submission
•   Eligibility verification
•   Quality reporting

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Testing

Look at processes for collecting and reporting diagnosis codes

(e.g., superbills and patient encounter forms)

Try handling processes with ICD-10:

•  If I had to select an ICD-10 code for the last patient, what
would it be?
•  If I had to prepare a claim with an ICD-10 code, how would
I do that?

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Testing

Test with payers and other business partners

•   Work with your vendors and other business partners to develop

a testing plan and schedule for ICD-10 transactions
•   Test how well your systems work together to send and receive
codes—focus on transactions that affect your practice most

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 Getting Ready for ICD-10:
Implementation

Prepare and monitor for ICD-10’s

potential impact on:
•  Coding productivity
•  Coding accuracy
•  Reimbursement
•  Vendor responsiveness

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MATTERS ICD-10 ICD-10
 Getting Ready for ICD-10:
Implementation

Sample steps to minimize ICD-10-related

challenges:
•   Eliminate coding backlogs before ICD-10 transition
•   Prioritize medical records for coding
•   Provide refresher training to address productivity and
accuracy issues
•   Develop a process for managing errors and resolving
vendor issues

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 CMS ICD-10 Resources

WHAT IS ICD-10? WHY ICD-10 WHY TRANSITION TO GETTING READY FOR CMS RESOURCES
MATTERS ICD-10 ICD-10
 Resources
CMS website:
www.cms.gov/icd10
•   Features fact sheets,
FAQs, and
implementation
guides, timelines, and
checklists

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 Resources

CMS ICD-10 Email

Updates provide
timely information

To sign up for updates:

1.  Go to cms.gov/icd10
2.  Select “CMS ICD-10 Industry
Email Updates” from left
navigation bar
3.  Click on “Sign up for update
messages”

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 Resources

Fact sheets on ICD-10

for providers, payers,
and vendors
•   Available on the Provider,
Payer, and Vendor
Resources pages of the
CMS ICD-10 website

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 Resources
ICD-10 Medscape
Modules

•   Expert Column: Preparing for

ICD-10: Now Is the Time
•   Video: ICD-10: Getting From
Here to There
•   Video: ICD-10 and Clinical
Documentation
Free continuing medical education (CME) and continuing education (CE)
credits available to physicians and nurses who complete ta brief post-test.
Accessible from CMS ICD-10 website: www.cms.gov/icd10

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 Resources

Road to 10 Tool: on Provider Resources page, cms.gov/ICD-10

The Road to10 can help you:

•   Understand the basics of

ICD-10

•   Build an ICD-10 action

plan to map out your

transition

•   Answer frequently asked

questions

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 Resources

Follow us on Twitter: @CMSgov

Join the conversation: Use #ICD10 to tweet about ICD-10

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