This document provides an overview of the transition from ICD-9 to ICD-10 coding systems in the United States. It discusses the key changes and differences between ICD-10-CM diagnosis coding and ICD-10-PCS inpatient procedure coding. It outlines the risks associated with the transition such as claim denials and delays. It provides checklists and recommendations for provider training and testing to facilitate a smooth transition.

1. Siji Susan Joy CCS, CPC, AHIMA
ICD-10 Ambassador

2. “Resubmission risks are expected, as large number of business
and process rules change in ICD -10 claims.”
According to MGMA, it costs most practices an average of $25 to
$30 to resubmit a corrected claim.
2

3. 3
Table of Contents
1 BACKGROUND 4
2 ICD -10-CM (DIAGNOSIS CODING SYSTEM) 5
3 ICD-10-PCS (INPATIENT PROCEDURAL CODING) 7
4 TRANSITION IN US 10
5 MEDICAL NECESSITY – CRUCIAL WITH ICD 10 11
6 CLINICAL DOCUMENTATION-CORNER STONE FOR ICD-10 12
7 PRELIMINARY PLANNING – CHECKLIST 13
8 WARNINGS 14
9 STRIDES FOR WELLNESS 15
10 RISK ASSESSMENT – FOCUS AREAS 16
11 TYPE OF TRAINING FOR PROVIDERS 17
12 TYPE OF TRAINING FOR PAYERS 18
13 REFERENCES 19

4. BACKGROUND
ICD 10 was implemented by World Health Organization (WHO) in 1993
to replace ICD 9 that was developed in 1970s .
ICD-10 has already been in use for many years in several countries.
ICD 10 in US refers to the US clinical modification ICD 10 – CM,
developed by National Center for Health Services (NCHS).
ICD-10 is already being used in the United States, but only for
mortality reporting done for the CDC (cause of death).
Center for Medicare and Medicaid (CMS ) developed ICD 10 PCS
which is the procedural coding system.
ICD-10-PCS will replace Volume 3 of ICD-9-CM as the inpatient
procedural coding system.
4

5. ICD -10-CM (DIAGNOSIS
CODING SYSTEM)
• ICD-10-CM practices 3 to 7 digits instead of the 3 to
5 digits used with ICD-9-CM
• Added Alphabetic characters to many ICD-10-CM
codes. Hence, ICD-10-CM will significantly impact
information technology, physician documentation,
and coding productivity when it get implemented
across all aspects of U.S. health care.
• In some instances, simply ICD 10, icd10 or just I-10
means ICD-10-CM.
NUMBER OF
DIGITS
• Category – Applies to digits 1,2 & 3
• Etiology, manifestation and severity – Applies to digits
4,5,6
• Extension – Applies to digit 7
CODE
FORMAT
5

6. ICD -10-CM (DIAGNOSIS
CODING SYSTEM)
• Acute or Chronic
• Initial Encounter, Subsequent Encounter, or Sequelae
• Right or Left
• Normal Healing, Delayed Healing, Nonunion, or Malunion
CAPTURES
CLINICAL
CONCEPTS
• Standardized
• Supports quality data exchange internationally to
track diseases and treatment outcomes.
• Interoperability – US and most international
• Expands codes for improved disease management ,
complications and safety issues
KEY BENEFITS
6

7. ICD-10-PCS (INPATIENT
PROCEDURAL CODING)
Both coding systems ICD 10
CM and ICD 10 PCS are
constituents of the MS-DRG
system. MS-DRG system is
used to pay for Medicare
services rendered by the
hospitals in US. Hence CMS
wanted to link ICD 10 PCS
to ICD 10 CM and so the
title carries “ICD 10”.
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HAS NO ASSOCIATION WITH WHO

8. ICD-10-PCS (INPATIENT
PROCEDURAL CODING)
• 7 alpha-numeric
NUMBER OF
DIGITS
• Section – Applies to digit 1
• Body system – Applies to digit 2
• Root operation – Applies to digit 3
• Body part – Applies to digit 4
• Approach – Applies to digit 5
• Device – Applies to digit 6
• Qualifier – Applies to digit 7
CODE
FORMAT
8

9. ICD-10-PCS (INPATIENT
PROCEDURAL CODING)
• Procedure definition is precise & accurate
• Detailed description of methodology , body parts
• Detailed and captures new technology
PROCEDURE
DEFINITION &
DESCRIPTION
• Cleaner logic of codes that lead to fewer coding
errors
• Accurate payment for new procedures
• Supports value based reimbursement activities
• Lesser RejectionsKEY BENEFITS
9

10. TRANSITION IN US
CPT/HCPCS will
continue to be used
without any change in
the current forms & will
remain same for
Outpatient services
Transition should
happen only in ICD 10
CM & ICD 10 PCS
WHO GETS AFFECTED
Physician providers &
Part B providers
covered by HIPAA
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11. MEDICAL NECESSITY –
CRUCIAL WITH ICD 10
Unnecessary ABN’s
due to changed
terminology that
challenges
registration staff &
physicians
Submitting
unspecified code
when specific code
is available
Lack of
documentation
Risk for Claim
Denial – Most
complex and costly
denials
CHALLENGES
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12. CLINICAL DOCUMENTATION-
CORNER STONE FOR ICD-10
Increased query
workflow &
rework for
physicians
Inaccuratecoding
Inappropriate
payment
Revenue loss risk
due to
resubmissions,
denials and claim
cycle delays
CHALLENGES
12

13. PRELIMINARY PLANNING -
CHECKLIST
•Clinicaldocumentation ,encounter forms/ superbills, PMS, EHR, contracts and public health and quality reporting protocols.
Identify Current Systems that uses ICD 9 CM & potential changes to workflow and
business processes
•Upgrade version to 5010
•Installation timelineand process to update
•Cross check contracts for inclusion of upgrades
•Choose PMS with ICD 10 ready
Accommodate ICD 10 codes in PMS
•Discuss on ICD 10 complianceplan and testing of their systems
•ICD 10 is more specific than ICD 9 and so payers may update terms of contracts, payment schedules, or reimbursement.
Discussion with clearing houses, billing services & payers on implementation plan.
•Online Courses
•Webinar
•Onsite Training
Training Need Analysis (TNA) for staff who code or have to know about the new codes
•Software updates,
•Reprintingof superbills, trainings, and related expenses
•Increased staffing due to slow down in productivity
Budget for ICD 10 implementation (expenses of systems changes, resource materials &
training
•Schedule test days
Conduct test transactions using ICD 10 codes between payers & providers
13

14. WARNINGS
Providers having problems coding ICD-10 claims.
Payers having problems processing ICD-10 claims
Lower reimbursements than expected
More payer rejections and denials
Delayed payment cycles
Returned phone calls from payers decreases
Medical Coders Quit
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15. STRIDES FOR WELLNESS
Improve
clinical
documentation
Will improve
reimbursement in
ICD 9 & backup
revenue to prepare
for ICD 10
Will justify
diagnoses and
services for payers
Quick processing
by coders
Meticulously
train all staffs
For accurate
coding and lesser
rejections
For ICD-10
compliance in
claims and billing
Test Timely,
Test Frequently
To identify areas of
improvement
before the
implementation
date
To identify new
business benefit
Open lines of
communication
between
Healthcare
Payers &
Providers
May have to invest
on dedicated
personal to attend
payer calls for
unreimbursed
claims
Why consider Clearing Houses ??
 Aware of problems faced by other
practices & assists to avoid problems
 May have better relations with payers
 Phone calls may be returned sooner 15

16. RISK ASSESSMENT – FOCUS
AREASICD-10 mandate has further strengthened the workflow automation for a payer. Hence reduce the process of resubmitting by adopting
automated resubmissionrisk analysis using BI tools. This will save back end work secondary to denied claims.
Medical Practices
Focus on CDI and Training
Identify high risk codes & probable areas of External
audits
Highest probability of medical necessity triggers
Dual Coding
Healthcare Payers
System remediation – Data and Database changes for
ICD -10 compliance
Claims and Billing – Date of service, Policy & contract
updates, changes to accept /route ICD-10 codes,
Changes to edits & pricing, Duplicate checking
Testing – Internal & External
16

17. TYPE OF TRAINING FOR
PROVIDERS
Training should begin no more than 6 months before
the compliance deadline – AHIMA recommendation
Physician
Practice
Coders
Training
Learn ICD- 10 diagnosis ONLY
16 Hours
Hospital
Coders
Training
Learn ICD-10 diagnosis and ICD-10 inpatient
procedure coding
50 Hours
Speciality-
specific ICD
10 Training
And
Advanced
CDI
Learn based on commonly used codes of the
speciality & documentation specifics
Need to know basis
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18. TYPE OF TRAINING FOR
PAYERS
CMS recommendations
Business
Processes &
IT Training
Use of new and modified HIPAA 5010 data elements
Policy updates
System & software changes – PMS, encoder code editing
program, DRG groupers & case mix indexes for IP
Claims and
Billing
Training
ICD 10 crosswalks, guidelines, prior authorizations and
documentations
Fraud and Abuse detection based on ICD 10 recommendations
Learn Dual Coded data set
Historical data analysis 18

19. REFERENCES
http://www.himss.org
http://library.ahima.org
http://www.cms.gov
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