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What Providers Need to Know About ICD-10


By Kerin Draak

The International Statistical Classification of Diseases and Related Health Problems, commonly referred to as ICD, is the international diagnosis classification set that translates the provider’s qualitative assessment into a quantitative value for reporting purposes. Most health care providers document their clinical impressions or assessments in words and not in numerical or even alphanumeric combinations. It is important that the ICD diagnostic code or value assigned to a provider’s clinical assessment matches as closely as possible for accurate reimbursement, statistical analysis and for quality patient care.

The United States is still using the outdated ninth edition, clinically modified for our use, ICD-9-CM when reporting diagnosis codes. Effective October 1, 2013, the Department of Health and Human Services (HHS) will require all health care providers to submit diagnosis codes using ICD-10-CM. Providers need to be informed consumers, just like the patients they treat. They need to stay current with all aspects of the health care industry, including the rules that govern health care.

Patients have the option to choose where they purchase their health care and will choose providers that they feel provide a quality health care experience and are affordable. If providers are unprepared for ICD-10-CM it could cause delayed and/or denied claims, resulting in unhappy patient/customers.

Providers should be an active partner in the patient-provider relationship by learning about ICD-10 to stay current in health care. Documentation rules and regulations play just as big a role in the delivery of quality health care as the latest advances in medicine. Some clinicians may challenge this philosophy, but the medical record is a very important piece of documentation. It is a legal document that needs to support the service billed and for the reimbursement received.

Don’t let documentation take a back seat either. Accurate documentation will be critical if one wishes to maintain a viable practice in the world of ICD-10. Providers should seek out educational opportunities through workshops, teleconferences or self-study as soon as possible to obtain a general sense of awareness. Providers who mistakenly assume that someone else is going to take care of this business-related aspect of health care and that ICD-10 will not affect them, will only have themselves to blame for not taking responsibility for their own ICD-10 education.

You may be saying to yourself that no one has ever had a problem with your documentation and that may be so. In large practice settings, there may be a team of experts that review and audit notes to ensure accurate diagnoses are assigned and the level of detail in your documentation may be sufficient for ICD-9 standards, but will hold up to the scrutiny of ICD-10 standards? What if you are in a small group setting or a solo practice? Does your staff know about ICD-10? The only way to truly know if your documentation will satisfy ICD-10 guidelines will be to conduct an audit.

Now is the time to prepare and make changes if needed to your documentation to ensure timely and accurate claims in 2013. The level of detail that will be required in your clinical assessment will be greater than ever before. Coders and billers cannot do this for you! Coders can only assign a diagnosis code that best matches your assessment. The less specific your assessment, the less specific the code assigned. Here is where the trouble lies; most payers will not reimburse for non-specified or unlisted diagnosis codes. The result will be unpaid claims.

There are several buzz words out there related to ICD-10, like laterality and specificity and they need to be understood and incorporated into your documentation.

Here is an example of why it is important to start taking at look at your documentation:

If your progress note today reads “Arm Pain”, the ICD-9-CM code that would be assigned is 729.5, which translates into “Pain in limb”.   The same diagnosis would be assigned M79.609 using ICD-10-CM, which translates to “Pain in unspecified limb.”

Whether or not carriers will reimburse unspecified codes is the bigger question. We are moving from a system that contains more than 17,000 codes to a system that contains over 141,000 codes and we need to accomplish this goal within the constraints of budget neutrality.

To assign a more specified code for the example above, your note would need to identify whether it was the left or right arm (laterality), was it the upper or lower part of the arm, was it the distal or proximal aspect of the lower arm, was this the first occurrence or a recurrent issue?  Your clinical assessment may not change but your documentation will need to change to allow for a greater level of specificity when assigning diagnosis codes using ICD-10-CM.

Now is the time to prepare yourself and your staff for the upcoming changes. Seek out educational opportunities today to avoid possible cash flow problem or compliance issue in the future.

An eighteenth-century English poet, Thomas Gray once wrote “Where ignorance is bliss, ‘Tis folly to be wise” resembles a common saying today, ‘What you don’t know cannot hurt you.’  I would guess that Thomas Gray was not born of an era of medical coding….and while it may be seem more comfortable not to know something, it will not keep you in compliance when the rules come October 1, 2013. A provider is responsible for knowing the rules and regulations that apply to all services he/she bills and now is the time to prepare.





Coding Educator, Prevea Health OB/GYN

Kerin has been involved in the health care field for over 18 years and is a member of the AAPC’s National Advisory Board. She earned her undergraduate degree from UW-Oshkosh in 1991, and then worked as a labor and delivery nurse in the hospital. After earning her graduate degree from UW-Madison in 1995, she began a nurse practitioner career. She has over 11 years of clinical experience in women’s health. Her coding career started in 2004 and she has been the coding educator for a 220+ multispecialty clinic. Since that time she has been involved in the development of the internal chart audit program. She has developed educational tools, guides, and policies for the clinic. She is a past presenter for the Wisconsin Medical Society at their Annual Symposium in 2007 and 2008 and has conducted several audio and day seminars on their behalf. She was a speaker at the AAPC national conferences in Orlando and Las Vegas.


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