On October 1, 2013, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. To accommodate the ICD-10 code structure, the transaction standards used for electronic health care claims, Version 4010/4010A, must be upgraded to Version 5010 by January 1, 2012. This document provides background on the ICD-10 transition, general guidance on how to prepare for it, and resources for more information.
About ICD-10
ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:
- ICD-10-CM for diagnosis coding
- ICD-10-PCS for inpatient procedure coding
ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.
ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.
The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.
Who Needs to Transition
ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. Everyone covered by HIPAA who transmits electronic claims must also switch to Version 5010 transaction standards. The change to ICD-10 does not affect CPT coding for outpatient procedures. Health care providers, payers, clearinghouses, and billing services must be prepared to comply with the Version 5010 and ICD-10 transitions, which means:
Health care providers, payers, billing services, clearinghouses, and other organizations that conduct electronic transactions should complete internal testing of Version 5010 systems in time to begin external testing with each other by January 1, 2011.
All electronic claims submitted on or after January 1, 2012, must use Version 5010 transaction standards. Electronic claims that do not use Version 5010 standards cannot be paid.
ICD-10 diagnosis codes must be used for all health care services provided in the U.S. on or after October 1, 2013. ICD-10 procedure codes must be used for all hospital inpatient procedures performed on or after October 1, 2013. Claims with ICD-9 codes for services provided on or after October 1, 2013, cannot be paid.
Preparing for the Transition
It is important to prepare now for the ICD-10 and Version 5010 transition. The following are steps you can take to get started:
Providers – Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and budget. Check with your billing service, clearinghouse, or practice management software vendor about their compliance plans. Providers who handle billing and software development internally should plan for medical records/coding, clinical, IT, and finance staff to coordinate on ICD-10 and Version 5010 transition efforts.
ICD-10 and Version 5010 Resources
Axxess will be offering a variety of Version 5010 and ICD-10 information, educational resources, and checklists. Visit our website regularly or subscribe to our news and updates page to receive latest information on HIPAA 5010 and ICD-10.
The Centers for Medicare & Medicaid Services (CMS) Web site www.cms.gov/ICD10 has official CMS resources to help you prepare for Version 5010 and ICD-10. CMS will continue to add new tools and information to the site throughout the course of the transition, so check the site frequently for updated resources.
