Making Our Health Care Delivery System More Efficient 

Important Update: The federal government has announced the new effective date for ICD-10 will be October 1, 2015.

ICD-10 is a diagnostic coding system that was implemented in 1993 by the World Health Organization (WHO) to replace ICD-9.  ICD-10 is already in use in almost every country in world except the United States.

The Federal government mandated the use of the ICD-10 code set because the ICD-9 coding system had several problems.  ICD-9 is not only outdated, it is out of space.  Medical science continues to make new discoveries, and there are no numbers to assign these new diagnoses.

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

1. 1. ICD-10-CM - for diagnosis coding
   2. ICD-10-PCS - for inpatient procedure coding

Who will have to use ICD-10?

HIPAA requires all covered entities that transmit electronic claims (providers, health plans and clearinghouses, etc.) to begin using ICD-10 diagnosis codes on October 1, 2015 (not just those who submit Medicare or Medicaid claims).

Important note: Worker's Compensation, auto and personal injury insurance are exempt from HIPAA; therefore they may not be using ICD-10, so your office may have to operate using two sets of codes, both ICD-9 and ICD-10.

Advantages of ICD-10

ICD-10 is expected to bring significant improvement in our healthcare system, including:

The ability to compare data with international data to track diseases and treatment resources;

Reduction in administrative expense for both physicians and payors due to:

• • Decreased need to include supporting documentation with claims
  • Less time for payors involved in managing claims

More specific diagnosis reporting means:

• • Fewer claim rejections and denials due to non-specific diagnoses
  • Fewer requests for clinical information
  • More precise pricing structure

Differences Between ICD-9 & ICD-10

ICD-9 has approximately 13,600 codes; ICD-10 has approximately 69,000 codes.  The new codes are more complex, contain more characters, require greater specificity and clinical detail, and will require increased documentation to support the codes reported.

The increase in clinical detail means that the code can provide more specific information about the diagnosis.  Specifically, ICD-10 will allow chiropractors to more precisely document clinical care and will potentially ensure more accuracy when payors determine medical necessity for the services rendered.  By providing more specific data with greater clinical detail, the conversion to the ICD-10 code sets will make our healthcare system more efficient and cost effective.

HIPAA and ICD-10 Electronic Claims

In 2009, HIPAA mandated that the health care industry use standard formats for electronic health care transactions.

Because the standard claim file format (837p, version 4010) could not support the upcoming ICD-10 code set changes, the Department of Health and Human Services mandated the conversion of all electronic health care transactions to the HIPAA-compliant 837p 5010 version by January 1, 2012.

The 837p 5010 claim file format provides for the expanded ICD-10 code length, and, in simple terms, provides a language that allows two different computers to speak the same billing/coding language.

As a result of ICD-10 and this federal mandate, HNS no longer accepts print image claim files (text files), or 837p claim files in the 4010 format.  Click here to review HNS's Electronic Claim Filing Requirements.

HNS strongly encourages all physicians to submit their electronic files to HNS in the required HIPAA compliant 837p 5010 format, directly from their practice management software system.  However, HNS offers an alternative for those physicians who are not yet ready to do so.  Please refer to the section titled "Office Ally".

ICD-10 and the CMS 1500 Claim Form

Because the existing CMS 1500 claim form (version 08/05) cannot accommodate the changes associated with ICD-10, a revised version of the CMS 1500 claim form (version 02/12) has been created.  The effective date for the use of this form was April 1, 2014.  As of the effective date, all paper claims, regardless of date of service, must be submitted on this revised form.

Important ICD-10 Deadlines:

• Effective October 1, 2015, payors will only accept electronic claim files submitted in the required 837p 5010 file format.
• Effective October 1, 2015, diagnoses reported on health care claims for dates of service on or after 10/01/15 must be represented by ICD-10 codes.