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ICD-10Sarah Enright
Provider Relations
What is ICD?• The ICD is the international standard diagnostic
classification for many health management purposes and clinical use including:– Analysis of the general health situation of population
groups– Monitoring of the incidence and prevalence of diseases
and other health problems in relation to other variables • Used to classify diseases and other health problems
recorded on many types of health and vital records.• Enables the storage and retrieval of diagnostic information
for clinical, epidemiological, and quality purposes.• Provides the basis for the compilation of national mortality
and morbidity statistics.
Who Maintains ICD-10?
• ICD-10-CM– National Center for Health Statistics (NCHS)– Centers for Disease Control and Prevention
(CDC)• ICD-10-PCS
– Centers for Medicare and Medicaid Services (CMS)
Federal Mandate
In January 2009, the Department of Health and Human Services issued a final rule requiring all HIPAA-covered entities to use ICD-10 diagnosis and procedure codes for HIPAA transactions with dates of service or dates of discharge on or after October 1, 2013.
HIPAA 5010 Compliance
Nomenclature Change
Why Transition to ICD-10?
• ICD-9 produces limited data about patients’ medical conditions and inpatient hospital procedures.
• ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice.
• The structure of ICD-9 limits the number of new codes that can be created; many ICD-9 categories are full.
Comparison ICD‐9‐CM ICD‐10‐CM
# of Characters 3‐5 Numeric
(+V and E codes)
3‐7 Alphanumeric
# of Codes ~ 13,500 ~ 68,000
Comparison ICD‐9‐CM ICD‐10‐PCS
# of Characters 3‐4 Numeric 7 Alphanumeric
# of Codes ~ 4,000 ~ 72,000
Diagnosis Codes
Procedure Codes
Structural Differences Between ICD-9 and ICD-10
Information Patterns
In general, ICD‐10 codes are more specific than ICD‐9.Certain cases exist where ICD‐9 is more specific than ICD‐10:
Method of detection eliminated in ICD‐10.Legal status and completeness of procedure eliminated in ICD‐10.
896.2 Traumatic amputation of foot S98.011A Complete traumatic amputation of (complete or partial) bilateral right foot at ankle level, initial encounterwithout mention of complication S98.012A Complete traumatic amputation of
left foot at ankle level, initial encounterS98.021A Partial traumatic amputation of right foot
at ankle level, initial encounterS98.022A Partial traumatic amputation of left foot
at ankle level, initial encounter
ICD‐9 Code and Description ICD‐10 Codes and Description
Differences in Specificity
Diagnosis Codes for Sprained and Strained Ankles: ICD-9-CM vs. ICD-10-CM
4 ICD‐9 Codes
845.00 Sprain and strain
of ankle, unspecified
site
845.01 Sprain and strain
of ankle, Deltoid
ligament/Internal
collateral ligament
845.02 Sprain and strain
of ankle,
Calcaneofibular
(ligament)
845.03 Sprain and strain
of ankle, Tibiofibular
(ligament) distal
72 ICD‐10 CodesS93.401A Sprain of unspecified ligament of right ankle ‐ initial
encounterS93.401D Sprain of unspecified
ligament of right ankle – subsequent encounter
S93.401S Sprain of unspecified ligament of right ankle – sequelaS93.402A Sprain of unspecified ligament of left ankle ‐ initial
encounterS93.402D Sprain of unspecified
ligament of left ankle – subsequent encounter
S93.402S Sprain of unspecified ligament of left ankle – sequelaS93.409A Sprain of unspecified
ligament of unspecified ankle ‐ initial encounter
S93.409D Sprain of unspecified ligament of unspecified ankle–
subsequent encounterS93.409S Sprain of unspecified ligament of unspecified ankle–
sequelaS93.421a Sprain of deltoid ligament of right ankle ‐ initial encounter
S93.421d Sprain of deltoid ligament of right ankle – subsequent
encounterS93.421q Sprain of deltoid ligament
of right ankle –Sequela S93.422a Sprain of deltoid ligament of left ankle ‐ initial encounter
S93.422d Sprain of deltoid ligament of left ankle – subsequent encounterS93.422q Sprain of deltoid ligament
of left ankle – sequelaS93.429a Sprain of deltoid ligament
of ankle unspecified ‐ initial encounter
S93.429d Sprain of deltoid ligament of unspecified ankle– subsequent
encounterS93.429q Sprain of deltoid ligament
of unspecified ankle– sequela S93.411A Sprain of calcaneofibular ligament of right ankle ‐ initial
encounterS93.411D Sprain of calcaneofibular ligament of right ankle – subsequent
encounter
S93.411S Sprain of calcaneofibular ligament of right ankle – sequelaS93.412A Sprain of calcaneofibular
ligament of left ankle ‐ initial encounter
S93.412D Sprain of calcaneofibular ligament of left ankle – subsequent
encounterS93.412S Sprain of calcaneofibular ligament of left ankle – sequela
S93.419A Sprain of calcaneofibular ligament of unspecified ankle ‐ initial
encounterS93.419D Sprain of calcaneofibular ligament of unspecified ankle–
subsequent encounterS93.419S Sprain of calcaneofibular ligament of unspecified ankleS93.431A Sprain of tibiofibular ligament of right ankle ‐ initial
encounterS93.431D Sprain of tibiofibular
ligament of right ankle – subsequent encounter
S93.431S Sprain of tibiofibular ligament of right ankle – sequelaS93.432A Sprain of tibiofibular ligament of left ankle ‐ initial
encounterS93.432D Sprain of tibiofibular
ligament of left ankle – subsequent encounter
S93.432S Sprain of tibiofibular ligament of left ankle – sequelaS93.439A Sprain of tibiofibular
ligament of unspecified ankle ‐ initial encounter
S93.439D Sprain of tibiofibular ligament of unspecified ankle–
subsequent encounterS93.439S Sprain of tibiofibular ligament of unspecified ankle–
sequelaS93.491A Sprain of other ligament of
right ankle (Internal collateral/talofibular) initial encounterS93.491D Sprain of other ligament of
right ankle (Internal collateral/talofibular) subsequent
encounterS93.491S Sprain of other ligament of
right ankle (Internal collateral/talofibular) sequela
S93.492A Sprain of other ligament of left ankle, initial encounter
S93.492D Sprain of other ligament of left ankle subsequent encounter
S93.492S Sprain of other ligament of left ankle sequela
S93.499A Sprain of other ligament of unspecified ankle initial encounterS93.499D Sprain of other ligament of unspecified ankle subs encounter
S93.499S Sprain of other ligament of unspecified ankle (Internal
collateral/talofibular) sequelaS96.211A Strain of intrinsic muscle and tendon at right ankle and foot level
initial encounterS96.211D Strain of intrinsic muscle and tendon at right ankle and foot level
subsequent encounterS96.211S Strain of intrinsic muscle and tendon at right ankle and foot level
sequelaS96.212A Strain of intrinsic muscle and tendon at left ankle and foot level
initial encounterS96.212DStrain of intrinsic muscle and tendon at left ankle and foot level
subsequent encounterS96.212S Strain of intrinsic muscle and tendon at left ankle and foot level
sequelaS96.219A Strain of intrinsic muscle and
tendon at ankle and foot level, unspecified side initial encounter
S96.219D Strain of intrinsic muscle and tendon at ankle and foot level, unspecified side subs encounter
S96.219S Strain of intrinsic muscle and tendon at ankle and foot level,
unspecified sideS96.811A Strain of other muscles and tendons at right ankle and foot level
initial encounter S96.811D Strain of other muscles and tendons at right ankle and foot level
subsequent encounter
S96.811S Strain of other muscles and tendons at right ankle and foot level
sequelaS96.812A Strain of other muscles and tendons at left ankle and foot level
initial encounterS96.812D Strain of other muscles and tendons at left ankle and foot level
subsequent encounterS96.812S Strain of other muscles and tendons at left ankle and foot level
sequelaS96.819A Strain of other muscles and
tendons at ankle and foot level, unspecified side initial encounter
S96.819D Strain of other muscles and tendons at ankle and foot level, unspecified side subs encounter
S96.819S Strain of other muscles and tendons at ankle and foot level,
unspecified side sequelaS96.911A Strain of unspecified muscle and tendon at right ankle and foot
level initial encounterS96.911D Strain of unspecified muscle and tendon at right ankle and foot
level subs encounterS96.911S Strain of unspecified muscle and tendon at right ankle and foot
level sequelaS96.912A Strain of unspecified muscle and tendon at left ankle and foot level
initial encounterS96.912D Strain of unspecified muscle and tendon at left ankle and foot level
subs encounterS96.912S Strain of unspecified muscle and tendon at left ankle and foot level
sequelaS96.919A Strain of unspecified muscle and tendon at ankle and foot level,
unspec. side initial encounterS96.919D Strain of unspecified muscle and tendon at ankle and foot level,
unspec. side subs encounterS96.919S Strain of unspecified muscle and tendon at ankle and foot level,
unspec. side sequela
Information Patterns
ICD‐9 has been evolving over the past 25‐30 years:Changes not consistent throughoutDiffering levels of specificity across chapters
ICD‐10 attempts to standardize levels of specificity and make them consistent across chapters.ICD‐10 classifies conditions by the stage of treatment vs. the episode of care.
ICD‐9 has been evolving over the past 25‐30 years:Changes not consistent throughoutDiffering levels of specificity across chapters
ICD‐10 attempts to standardize levels of specificity and make them consistent across chapters.ICD‐10 classifies conditions by the stage of treatment vs. the episode of care.
ICD‐10 Codes and Descriptions ICD‐9 Codes and Descriptions
026.851 649.51
Spotting complicating pregnancy, first trimester Spotting complicating pregnancy, delivered
026.852 649.53
Spotting complicating pregnancy, second trimester Spotting complicating pregnancy,
026.853 antepartum
Spotting complicating pregnancy, third trimester
026.859
Spotting complicating pregnancy, unspecified trimester
Information Patterns
More extensive vocabulary of clinical concepts, body part specificity, patient encounter information, and other components from which codes are built.
ICD‐9 Code and Description ICD‐10 Codes and Descriptions
87353 S01521A Laceration with foreign body of lip, initial encounter
Complicated open wound S01511A Laceration without foreign body of lip, initial encounter
of lip S01521D Laceration with foreign body of lip, subsequent encounter
S01511D Laceration without foreign body of lip, subsequent encounter
S01541A Puncture wound with foreign body of lip, initial encounter
S01531A Puncture wound without foreign body of lip, initial encounter
S01541D Puncture wound with foreign body of lip, subsequentencounter
Differences in Classification
Recommended Discovery Tasks for ProvidersJanuary to June 2011• Identify competing projects and determine the priority of
ICD-10.• Identify current systems that use ICD-9 codes.• Identify current reports that contain ICD-9 codes.• Identify current business processes that use ICD-9 codes.• Review vendor contract language to determine if ICD-10
system upgrades are required and included in contract.• Analyze business processes to identify changes required.
Recommended Discovery Tasks for ProvidersJanuary to June 2011 (continued)• Contact system vendors to determine if and when an
ICD-10 complete upgrade will be offered.• Analyze revenue and productivity impacts.• Assess staff training needs.• Estimate costs and budgetary implications.• Contact clearinghouses, billing services, and payers to
determine when they will be ready to test.
Recommended Planning Tasks for Providers
July – September 2011• Develop an implementation plan.• Identify assumptions and risks to
compliance.• Update encounter forms and other
forms.
ICD-10 on Provider Home Page of BCBSRI.com
ICD-10 Landing Page on BCBSRI.com
ICD-10 Noncompliance
• Your claims and other transactions may be rejected.
• You will need to resubmit them with the ICD-10 codes.
• This may result in delays in reimbursement.
Thank you!