ICD-10 Code Set to Replace ICD-9
ICD-10 Deadline Approaching: Oct. 1, 2015
All signs indicate the ICD-10 (International Classification of Diseases, Revision 10) will be implemented on Oct.1. Given this situation the American Medical Association is focusing on steps to ease the transition and mitigating the potential disruption in claims processing, physicians’ workflow and patients’ access to care. The American Association of Professional Coders has a 30 day action plan to meet the deadline.
CMS and AMA Announce Efforts to Help Providers Get Ready for ICD-10
On July 6, with less than three months remaining until the Oct. 1 deadline, the Centers for Medicare & Medicaid Services (CMS) and AMA announced efforts to continue to help physicians prepare for ICD-10. Read CMS’s guidance in response to the AMA’s concerns.
CMS posts clarifying ICD-10 guidance
CMS has updated guidance on the ICD-10 coding transition following requests from the AMA to clarify several questions. The clarifying FAQs are consistent with the original announcement and provide added clarity of the term "family of codes" and the flexibility pertaining to front-end claims processing, in addition to post-payment audits. The AMA is also working with CMS to develop a version of the FAQs that is specifically geared toward physicians since the revised document is aimed at multiple audiences (e.g., Medicare contractors, CMS regional offices, and other providers).
The differences between ICD-9 and ICD-10 are significant and physicians and practice management staff need to start educating themselves now about this major change so that they will be able to meet the compliance deadline of Oct. 1, 2015.
ICD-10-CM codes are the ones designated for use in documenting diagnoses. They are 3-7 characters in length and total 68,000, while ICD-9-CM diagnosis codes are 3-5 digits in length and number over 14,000. The ICD-10-PCS are the procedure codes and they are alphanumeric, 7 characters in length, and total approximately 87,000, while ICD-9-CM procedure codes are only 3-4 numbers in length and total approximately 4,000 codes. ICD-10-PCS is only used for coding hospital inpatient procedures. CPT remains the code set for reporting procedures and services in offices and outpatient settings.
Moving to ICD-10 is expected to impact all physicians. Due to the increased number of codes, the change in the number of characters per code, and increased code specificity, this transition will require significant planning, training, software/system upgrades/replacements, as well as other necessary investments.
The Final Rule requiring the replacement of ICD-9 with ICD-10 was published in January 2009. At that time, the compliance date was set for Oct. 1, 2013.
In 2012, the Department of Health and Human Services (HHS) announced a one year delay of ICD-10 implementation, which pushed the date back to Oct. 1, 2014. At the time, then AMA Board Chair Steven J. Stack, MD commented, "The AMA appreciates the administration's decision to provide a one year delay in response to AMA advocacy, but we have urged CMS to do more to reduce the regulatory burdens on physician practices so physicians can spend more time with patients."
On Aug. 4, 2014, new regulation published by HHS set the latest compliance date as Oct. 1, 2015. This additional one-year delay in the implementation of ICD-10 came from language inserted into the Protecting Access to Medicare Act of 2014, which was signed into law on April 1, 2014. The new regulation also clarifies that ICD-9 will continue to be required until Sept. 30, 2015.
The AMA continues to take many steps with the Administration to address physician concerns with ICD-10 and the multiple reporting programs and burdens associated with them, in greater depth.
The AMA continues to advocate to CMS that robust end-to-end testing needs to occur well in advance of the compliance deadline and with as many physician practices as possible. Testing is the best action the industry can take to ensure that claims will process without problems after the switch to ICD-10.
Medicare has completed end-to-end testing in January and April 2015 and will conduct a final round of testing in July 2015. The testing is being done with approximately 2,550 volunteers. The goals of this testing are to demonstrate that:
- Physicians, other health care providers, and other submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems,
- CMS software changes made to support ICD-10 result in appropriately adjudicated claims, and
- Accurate Remittance Advices are produced.
Testing in January was completed on 14,929 claims from 661 submitters. The acceptance rate was *1 percent, which is well below the usual Medicare acceptance rate of 95-98 percent. The acceptance rate of the April testing was 88 percent on 23,138 claims from 875 submitters.
The following are the results of the testing weeks.
- March 2014: 89 percent acceptance on 127,000 claims from 2,600 submitters
- November 2014: 76 percent acceptance on 13,700 claims from 500 submitters
- March 2015: 91.8 percent acceptance on 9,000 claims from 775 submitters
- June 2015: 90 percent acceptance on 13,100 claims from 1,238 submitters
Physicians should contact their Medicare Administrative Contractor (MAC) for more information on the end-to-end and acknowledgement testing.
Medicare continues to update the National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). MLN Matters #8691 provides information on recent changes to 29 NCDs. MLN Matters MM9807 provides information on ICD-10 Conversion/Coding Infrastructure Revisions/ICD-9 Updates to National Coverage Determinations (NCDs).
For LCDs, a list of LCDs converted to ICD-10 is available on the LCDs by Contractor Index. Use the scroll box on the index to select your MAC and use the "Submit" button to view a list of states that the specified MAC services. You can then select your MAC name from the table to view the future translated LCDs.
Both the ICD-9 and ICD-10 code sets are currently under a partial freeze during the implementation of ICD-10. The recent delay in the implementation date of ICD-10 to Oct. 1, 2015 has also extended the partial freeze. With the new compliance date of Oct. 1, 2015, the partial code freeze will continue through Oct. 1, 2015. Regular updates to ICD-10 will begin on Oct. 1, 2016, one year after the implementation deadline. No updates will be made to ICD-9 after Oct. 1, 2015, as the code set will no longer be valid.
The ICD-9-CM Coordination & Maintenance Committee Meeting initiated the partial freeze in 2010. The ICD-9 Coordination & Maintenance Committee continues to meet twice a year during the freeze. At these meetings the public will be allowed to comment on whether or not requests for new diagnosis and procedure codes should be created based on the need to capture new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10 on or after Oct. 1, 2016, once the partial freeze is ended.
What is “ICD-10”?
“ICD-10” is the abbreviated way to refer to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS).
Explain the difference between ICD-10-CM and ICD-10-PCS.
ICD-10-CM is the diagnosis code set that will be replacing ICD-9-CM Volumes 1 and 2. ICD-10-CM will be used to report diagnoses in all clinical settings. ICD-10-PCS is the procedure code set that will be replacing ICD-9-CM Volume 3. ICD-10-PCS will be used to report hospital inpatient procedures only.
Will ICD-10-PCS replace CPT®?
No. ICD-10-PCS will be used to report hospital inpatient procedures only. The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) will continue to be used to report services and procedures in outpatient and office settings.
Do I have to upgrade to ICD-10?
Yes. The conversion to ICD-10 is a HIPAA code set requirement. Providers, including physicians, are HIPAA “covered entities”, which means that you must comply with the HIPAA requirements.
Who else has to upgrade to ICD-10?
Health care clearinghouses and payers are also HIPAA covered entities, so they are required to convert to ICD-10 as well.
I thought HIPAA code set standards only applied to the HIPAA electronic transactions. What if I don’t use the HIPAA electronic transactions?
It is correct that HIPAA code set requirements apply only to the HIPAA electronic transactions. But, it would be much too burdensome on the industry to use ICD-10 in electronic transactions and ICD-9 in manual transactions. Payers are expected to require ICD-10 codes be used in other transactions, such as on paper, through a dedicated fax machine, or via the phone.
Why is ICD-9 being replaced?
The ICD-9 code set is over 30 years old and has become outdated. It is no longer considered usable for today’s treatment, reporting, and payment processes. It does not reflect advances in medical technology and knowledge. In addition, the format limits the ability to expand the code set and add new codes.
The ICD-10 code set reflects advances in medicine and uses current medical terminology. The code format is expanded, which means that it has the ability to include greater detail within the code. The greater detail means that the code can provide more specific information about the diagnosis. The ICD-10 code set is also more flexible for expansion and including new technologies and diagnoses. The change, however, is expected to be disruptive for physicians during the transition and you are urged to begin preparing now.
When do I have to convert to ICD-10?
All services and discharges on or after the compliance date must be coded using the ICD-10 code set. The compliance date is Oct. 1, 2015. The necessary system and workflow changes need to be in place by the compliance date in order for you to send and receive the ICD-10 codes.
What will be the cost to convert to ICD-10?
In February 2014, the AMA published a report by Nachimson Associates updating cost data for physicians to comply with ICD-10. The study updated costs from an earlier 2008 study, the highlights of which are discussed in a press release. The report found that small practices can expect to spend anywhere between $56,639 to $226,105.
The new estimates factor in the costs associated with purchasing new software to accommodate the new codes. Issued in conjunction with the report and press release was a letter to Secretary Sebelius reiterating the AMA’s request that ICD-10 be repealed because it is a costly, unfunded mandate for practicing physicians. While the AMA continues to seek a repeal of ICD-10, it nonetheless remains a federal mandate, and physicians are urged to prepare for the compliance date of Oct. 1, 2015.
- View Nachimson Advisors' response to the February 2015 article in the Journal of AHIMA, "Survey Examines ICD-10 Implementation Costs in Small Physician Offices."
- View Nachimson Advisors' response to the November 2014 article in the Journal of AHIMA, "Cost of Converting Small Physician Offices to ICD-10 Much Lower than Previously Reported."
What if I’m not ready by the compliance deadline?
Any ICD-9 codes used in transactions for services or discharges on or after the compliance date will be rejected as non-compliant and the transactions will not be processed. You will have disruptions in your transactions being processed and receipt of your payments. Physicians are urged to set up a line of credit to mitigate any cash flow interruptions that may occur.
What do I need to do now to prepare for the conversion to ICD-10?
There are several steps you need to take to prepare for the conversion to ICD-10.
- Begin by talking to your practice management or software vendor. Ask if the necessary software updates will be installed with your upgrades for the Version 005010 (5010) HIPAA transactions. If you do not use the HIPAA transactions, determine when they will have your software updates available and when they will be installed in your system. Your conversion to ICD-10 will be heavily dependent on when your vendor has the upgrades completed and when they can be installed in your system.
- Talk to your clearinghouses, billing service, and payers. Determine when they will have their ICD-10 upgrades completed and when you can begin testing with them.
- Identify the changes that you need to make in your practice to convert to the ICD-10 code set. For example, your diagnosis coding tools, “super bills”, public health reporting tools, etc.
- Identify staff training needs and complete the necessary training.
- Conduct internal testing to make sure you can generate transactions you send with the ICD-10 codes.
- Conduct external testing with your clearinghouses and payers to make sure you can send and receive transactions with the ICD-10 codes.
AMA offers planning tools to increase ICD-10 understanding and readiness.
- ICD-10 Action Plan: Your 12-Step Transition Plan for ICD-10
Practice Tool written by the AMA CPT Medical Informatics Department
With the recent delay, implementation of ICD-10-CM is expected to be Oct. 1, 2015. But transitioning to ICD-10 needs to begin now. This ICD-10 practice tool offers 12 critical steps along with tables and forms to help you make a smooth transition. A short glossary and list of AMA ICD-10 resources are also included. Release date: Sept. 4, 2012.
- What You Need to Know for the Upcoming Transition to ICD-10-CM
White Paper written by the AMA CPT Medical Informatics Department
ICD-10 represents a significant improvement over ICD-9, but structural differences make converting complex. Learn more about this as well as code set differences, reasons for the conversion, crosswalking concerns, and transition tips.
Release date: June 1, 2012.
AMA testimony to the National Committee on Vital and Health Statistics’ Subcommittee on standards regarding the planning and implementation of the updated HIPAA transactions and code sets, December 10, 2009
Note: A few of the following resources were created prior to the deadline delay and are not updated to show the October 1, 2015 compliance date.
- CPT Assistant Article on Clinical Documentation & ICD-10
The "Clinical Documentation Assessment: Looking at the Patterns Between the ICD-9-CM and ICD-10-CM Coding Systems" article published in the CPT Assistant Bulletin in June 2014 provides overviews of conducting a documentation assessment and the similarities and differences between ICD-9-CM and ICD-10-CM. Tables explain the coding concepts that are the same from ICD-9-CM and those that are new in ICD-10-CM and gives examples to demonstrate the coding concepts.
- Article on Preparing for ICD-10
"The Current State of ICD-10 & Preparing for It" was published in the November/December 2013 Missouri Medicine Journal. The article provides an overview of ICD-10, the AMA’s advocacy against it, and information on how to prepare for it. The article is posted on here with the permission of the Missouri State Medical Association.
- AMA White Paper on ICD-10, EHRs, and Administrative Simplification
The AMA has published a white paper that discusses the promised benefits of ICD-10, EHRs, and administrative simplification. The paper describes the initial regulations and anticipated gains from them. Recommendations on what practices can do to achieve these benefits are also provided.
Tip Sheet Series
- Complete an ICD-10 Impact Assessment
- Talk to Your Vendors about ICD-10
- Assess Your Documentation for ICD-10
- Determine Your Training Needs
- Talk to Your Payers about ICD-10 Reimbursement Changes
- Testing Your ICD-10 Readiness
- Prevent Cash Flow Interruptions with ICD-10
5010 and ICD-10: What They Are and How to Prepare for Them Watch this archived webinar that provides an overview on implementing the HIPAA 5010 transactions and ICD-10.
ICD-10 Fact Sheet Series
- #1 ICD-10 101: What It Is and Why It's Being Implemented
- #2 The Differences Between ICD-9 and ICD-10
- #3 ICD-10 Timeline: Meeting the Compliance Date
- #4 Implementing ICD-10 in Your Practice - Part 1
- #5 Implementing ICD-10 in Your Practice - Part 2
- #6 Testing your Readiness for ICD-10
- #7 Crosswalking Between ICD-9 and ICD-10
- #8 Partial Freeze to ICD-9 and ICD-10 for Smoother Transition
- AMA Training & Events – Choose from a variety of live event training, online modular training or pre-recorded webinar options to aid in your understanding of ICD-10
- AMA Print Resources – AMA publishes ICD-10 codebook as well as supplementary ICD-10 titles that cover topics like documentation, anatomy and physiology, mapping, and correct coding
- AMA Data Files – Begin testing your electronic systems now with an ICD-10 Data File created by the AMA
ICD-10 Implementation Tracking Tool - This tool is available to non-AAPC members. You just need to create an account to access the tracking tool and activities checklists. Please note: This link takes you out of the AMA Web site.
- Road to ICD-10 – Free tools and webcasts specific for helping small physician practices implement ICD-10.
- Online ICD-10 Implementation Guide
- ICD-10 Implementation Guide for Large Practices