The first step to surviving change is anticipating it. Suppliers should anticipate that the current diagnosis coding system will change substantially in the future. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) will most likely be replaced with the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

It may be another 2 or 3 years before the change is fully implemented, but it is not too early to learn about this updated classification system and develop a plan to ensure smooth claims processing.

Many health care professionals believe that ICD-9-CM has become outdated and obsolete. In their view, ICD-9-CM is no longer capable of addressing the increased need for more specific codes, particularly codes that address new technology, emerging diseases, and medical advances. Because of these concerns, the United States has been under pressure to implement ICD-10-CM, which will provide greater specificity in reporting medical conditions. ICD-10-CM is a clinical modification of the World Health Organization’s ICD-10 for use in the United States—one of the last of the developed countries to make the decision to change to ICD-10.

A look at the current draft of the ICD-10-CM coding system reveals that most codes in the new system provide greater specificity and more clinical information, as well as additional information relevant to ambulatory and managed care encounters. ICD-10-CM is designed to allow for future code expansion. General medical terminology, as well as the disease classification used in ICD-9-CM, has been updated to be consistent with current accepted clinical practice. The greater specificity will provide more detailed information to assist providers and payors in establishing appropriate reimbursement rates, and help to monitor resource utilization to improve overall care.

A brief comparison between the ICD-9-CM coding system and the proposed ICD-10-CM demonstrates the challenges of this implementation. ICD-9-CM contains approximately 13,000 diagnosis codes. The current draft version of ICD-10-CM contains approximately 60,000 diagnosis codes. ICD-10-CM codes are alphanumeric and include all alphabet letters except the letter “U,” which is reserved for new diseases of uncertain etiology. ICD-9-CM is primarily composed of numeric digits, with the exception of the alphabetic letters used in E codes and V codes. ICD-9-CM’s E codes and V codes are incorporated into the main classification in ICD-10-CM. The alphanumeric character structure of ICD-10-CM may present a unique challenge not experienced with ICD-9-CM. The likelihood of confusing both the letter “I” with the numeral “1" (one) and the letter “O” with the numeral “0” (zero) is significant.

ICD-10-CM codes can be expanded to as many as seven characters while ICD-9-CM codes can be expanded to a maximum of only five characters. For example, ICD-9-CM provides one code assignment for a decubitus ulcer (707.0). This code cannot identify the size, location, depth, or number of decubitus ulcers. In comparison, ICD-10-CM provides for the assignment of 60 individual codes related to decubitus ulcers. These codes provide information related to size, depth, location, and whether the patient has multiple decubitus ulcers. An example of one of the 60 possible ICD-10-CM codes associated with decubitus ulcers is L89.031—decubitus ulcer of the right lower back limited to breakdown of the skin.

New Features Address Diabetes
ICD-10-CM offers several new or expanded features. In the diabetes mellitus code section, for example, ICD-10-CM provides diabetes code assignment specific to the type of diabetes (type 1 or type 2) or cause of the diabetes, rather than linking diabetes codes to whether the patient is insulin dependent or non-insulin dependent as in ICD-9-CM. ICD-10-CM also provides an additional code assignment to identify any insulin usage (Z79.5). For example, in the ICD-10-CM coding system, a type 2 diabetic who is controlled on insulin and who experiences diabetic nephropathy would be assigned the code E11.21—type 2 diabetes mellitus with diabetic nephropathy—and Z79.5, long-term current use of insulin. Under the current ICD-9-CM coding system, 250.40 (diabetes mellitus with renal manifestations [type 2]) is not stated as uncontrolled; and 583.81 (nephritis and neuropathy in diseases classified elsewhere) would be assigned.

Another new feature of ICD-10-CM, and of particular interest to readers who are coding buffs, is the provision of expanded “excludes” notes guidance. “Excludes 1” notes designate codes that can never be used together. “Excludes 2” notes indicate that the excluded condition is not a part of or included in the code.

A smooth coding transition should start with an estimate of budget needs for staff education—particularly billing staff. The ability of the staff to understand what conditions the diagnosis codes represent is critical to ensuring that the codes support the medical necessity of each service or supply. If your company uses commercial software, you should ensure that your software provider is keeping up with the announced changes. If your software vendor is not prepared for the implementation of ICD-10-CM, your company may suffer the consequences of being unable to submit claims and receive reimbursement for services provided. The National Center for Health Statistics of the Centers for Disease Control and Prevention has indicated that it will make available the following tools that are essential for a smooth transition to ICD-10-CM: a sample database version; a crosswalk from ICD-9-CM to ICD-10-CM; educational materials; and the official coding guideline. Remember that the ICD-10-CM codes cited in this article are not currently valid and should not be used clinically or for reimbursement purposes until the final notice is posted by the Secretary of the Department of Health and Human Services (DHHS). Although major coding changes are coming, it is unclear exactly when these changes will take place. More than likely, implementation will be in 2007, allowing you time to plan for the change. In the meantime, use the current code set (ICD-9-CM). Currently, ICD-9-CM codes are revised and updated every October 1. CMS has indicated that it will no longer allow a 90-day grace period for suppliers to learn about the revised and/or discontinued ICD-9-CM codes. Effective for dates of service on and after October 1, 2004, no further 90-day grace periods will apply for the annual ICD 9-CM updates. You must bill using the diagnosis code that is valid for that date of service.

A provision of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires that the Secretary of the DHHS provide for the addition of new diagnosis and procedure codes on April 1 of each year. Starting in fiscal year 2005, new ICD-9-CM codes will go into effect twice a year, on April 1 and October 1.

This article is not intended to be legal advice or legal advice/opinion on any specific facts or circumstances. The content is general information only.

Marcia Castillo, BAAS, RHIT, CCS, is a paralegal - medical information analyst with the Health Care Group of Brown & Fortunato PC, an Amarillo, Texas-based law firm. She can be reached at (806) 345-6354 or mcastillo@bf-law.com.