1. ICD-10:
What Do The Experts Have to Say?
Brenda Edwards, CPC, CPMA, CPC-I, CEMC
Coding & Compliance Specialist
KaMMCO

2. Who are the Information Sources?
• CMS
▫ Centers for Medicare and Medicaid Services
• WHO
▫ World Health Organization
• AAPC
▫ American Academy of Professional Coders
• BCBS of KC
▫ Blue Cross Blue Shield of Kansas City
• AHIMA
▫ American Health Information Management Association

3. What Needs to Happen Before ICD-10?
• Transition to HIPAA 5010 transaction standards
What is 5010?
ELECTRONIC TRANSACTIONS
• The transaction and code sets rule was part of the original
HIPAA law from 1996 to adopt standards
▫ ANSI 4010A
▫ Adoption of CPT, ICD-9, and HCPCS as standard code sets
▫ Standardized electronic reporting format for covered transactions
(claims, remittance, etc.)
• Current versions lack functionality
▫ 1/2009 Secretary of HHS adopted Version 5010, Version D.0, and
NCPDP 3.0 as the HIPAA standard code sets

4. What are the Improvements?
• More specific reporting of data
▫ Anesthesia all time based (no longer units)
▫ Provider physical address no longer P.O. Box (not billing
address)
▫ Zip + 4 zip codes (i.e. 66610-9685)
9998 if unknown
• Technical reports
▫ More consistent data/less confusing
▫ (Transaction 277)
Claims status request and reply
Recoupment
• Distinguishes
▫ Principal and admitting diagnosis
▫ External cause of injury
▫ Patient reason for visit
▫ “Present on admission”
• Supports monitoring illness mortality rates
• Accommodates ICD-10-CM and ICD-10-PCS

5. 5010 (and ICD-10) Compliance Timelines
Date Compliance Step
January 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic
claims
December 31, Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance
2010
January 1, 2011 • Payers and providers should begin external testing of Version 5010 for electronic claims
• CMS begins accepting Version 5010 claims
• Version 4010 claims continue to be accepted
December 31, External testing of Version 5010 for electronic claims must be complete to achieve Level II
2011 Version 5010 compliance
January 1, 2012 • All electronic claims must use Version 5010
• Version 4010 claims are no longer accepted
• ICD-10 end-to-end testing begins
October 1, 2013 • Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis
and inpatient procedures
• CPT codes will continue to be used for outpatient services
http://www.cms.gov/ICD10/03_ICD-10andVersion5010ComplianceTimelines.asp#TopOfPage

6. Steps to Prepare for Version 5010
• Talk with vendors
▫ Accept both 4010 and 5010?
• Discuss implementation plans with clearinghouses, billing
services, and payers
▫ Be proactive, don't wait
• Conduct testing on Version 5010 codes with payers and
clearinghouses
▫ Testing is critical

7. 5010 Transition Information
http://www.cms.gov/MFFS5010D0/
http://www.cms.gov/ICD10/downloads/w5010BasicsFctSht.pdf

8. ICD-10

9. Why ICD-10-CM?
• Used throughout the world
▫ Classify causes of mortality (death records)
• CM = Clinical Modification for U.S.
▫ Used for morbidity (illness) statistics
▫ Canada (CA), Australia (AM) and other countries
have developed clinical modifications
• Advancing technology
• ICD-9 has run out of codes
▫ Used for 30 years
• Codes impact all aspects of billing and
reimbursement for providers, facilities, and
health plans

10. ICD-10 Provider Office Changes
• It WILL affect every aspect of the provider office
http://www.aapc.com/ICD-10/office-map/index.aspx

11. Steps to Prepare for ICD-10
• Identify your current systems/processes that use ICD-9 codes
▫ ICD-10 codes will take their place
• Talk with your payers
▫ How will ICD-10 implementation might affect your contracts?
• Identify potential changes to work flow and business processes
• Assess staff training needs
▫ Identify staff who need to know the new codes
▫ Coding professionals recommend training place 6 months prior to October 1,
2013
▫ CPC’s will need to be re-certified
All certified coders are required to pass the validation by September 30, 2014 to
maintain certification
http://www.aapc.com/ICD-10/faq.aspx#implemented
• Budget for time and costs related to ICD-10 implementation
▫ System changes,
▫ Resource materials
▫ Training
▫ Assess costs
Software updates
Reprinting of superbills/encounter forms
Training and related expenses
http://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOfPage

12. CMS FAQ’s
• What should coders be doing now?
▫ Learn structure, organization, and unique features of ICD-10
▫ Learn system impact
▫ Assess areas of strength/weakness (anatomy, terminology)
Review knowledge concepts
Additional training to refresh/expand knowledge
▫ Intensive coder training approximately 6 -9 months prior
to implementation
Allocate 16 hours of ICD-10 training
Adequate for most coders
Very proficient ICD-9 coders may not need that much
Full text available at:
http://questions.cms.hhs.gov/app/answers/detail/a_id/10024/kw/icd-10

13. CMS FAQ’s
• When will ICD-9 codes stop being accepted?
▫ ICD-9-CM codes will not be accepted for services provided on
or after October 1, 2013.
▫ Note: ICD-10 codes will not be accepted for services prior to
October 1, 2013
http://questions.cms.hhs.gov/app/answers/detail/a_id/10019/p/8,11,981

15. How Painful Will This Be$
• Impact to providers
▫ Documentation must support the code
▫ New coverage policies, edits, fee schedules
▫ Greater specificity
▫ Explanations to patients
▫ Payer contracts
▫ Testing orders
▫ Budget
▫ Training
▫ System upgrades
Hardware
Software
Interface

16. Impact on Health Plans
• New or revised contracts with providers
• Determinations
▫ Coverage
▫ Payment
• Medical review policies
• Plan structures
• Statistical reports
• Actuarial projections
• Fraud and abuse monitoring
• Quality measurements
• Testing

17. Impact for Billing and Collections
• Confusion (physicians, patients, providers, plans)
• Increased denials?
• Transition period using ICD-9 and ICD-10-CM
• Privacy concerns- more specificity and detail
• Delay in payment$
• Increased phone calls and questions from patients

18. Steps to ICD-10-CM Implementation
• Project team and impact analysis
• Timeline and budget
• Documentation needs analysis
• Communication and training plan
• IT design and development
• Process analysis and needs assessment
• Deployment of ICD-10

19. Freeze on Code Sets?
• In the inpatient prospective payment system (IPPS)
proposed rule for fiscal year (FY) 2011, CMS states:
▫ We welcome additional input on having the last
regular code updates to ICD-9-CM and ICD-10 on
October 1, 2011, and to only add codes for new
technologies and diseases on October 1, 2012 and
2013. We also welcome additional input on having
the next regular update to ICD-10 occur again on
October 1, 2014.
• Providers, payers, clearinghouses, and health
information technology vendors will not have to
simultaneously keep pace with code updates while also
reconfiguring their existing systems for ICD-10-
CM/PCS.

20. How Big is THE Change?
•17,000 •141600
▫ This number represents ▫ 72,500 ICD-10-PCS
▫ 69,100 ICD-10-CM
only ICD-9-CM codes
▫ Room to move up
to 155,000
An increase of 1,000 new codes
from 2009 to 2010
1,982 added
983 deleted
1,029 revised

21. ICD-9 to ICD-10 Comparison
ICD-10 Category ICD-9
A00-B99 Infectious disease and parasites 001-139
C00-D49 Neoplasm 140-239
D50-D89 Blood diseases 280-289
E00-E90 Metabolic and nutritional diseases 240-279
F01-F99 Mental health 290-319
G00-G99 Nervous and sensory systems 320-389
H00-H59 Eye disease 360-379
I00-I99 Circulatory system 390-459
J00-J99 Respiratory system 460-519
K00-K94 Digestive system 520-579
L00-L99 Skin disease 680-709
M00- M99 Musculoskeletal (including Dental) 710-739

22. ICD-9 to ICD-10 Comparison
ICD-10 Category ICD-9
N00-N99 Genitourinary 580-629
O00-O99 Pregnancy and child birth 630-676
P00-P96 Newborn 764-779
Q00-Q99 Congenital, deformations, chromosomal 740-759
abnormalities
R00-R99 Signs, symptoms, and abnormal lab 780-799
S00-T88 Injury, poisoning, complications, fractures, & 800-999
other external causes
V01-Y95 External causes of morbidity “E” codes
Z00-Z99 Health status/contact with health services “V” codes

23. ICD-9 Format
• Classify conditions according to the part of the
body affected rather than to those dealing with
the underlying generalized disease.
• http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

24. ICD-10-CM Format
Numeric
Alpha or Numeric
Alpha
xxx xxx X
Etiology,
Extension
Category Anatomical
Site, Severity

25. Categories and Subcategories
The “Block”
• First digit
▫ Alpha
▫ “U” not used-saved for newly
discovered diseases of unknown
etiology • S55 Injury of blood vessels at forearm
• Second and Third digits level
▫ Numeric
• Fourth digit • S55.0 Injury of ulnar artery at forearm
▫ Defines site, etiology, manifestation
or state of disease/condition
• S55.01 Laceration of ulnar artery at
• Fifth digit
forearm level
▫ Most precise level of specificity
• Sixth digit • S55.012 Laceration of ulnar artery at
▫ Defines more specificity forearm level, left arm
• Seventh digit
▫ Codes for injuries and poisonings • S55.012A Laceration of ulnar artery at
and other external causes forearm level, left arm, initial
encounter

26. Categories and Subcategories
Extensions • T45.7x2 Poisoning by anticoagulant
o Dummy placeholders (x) antagonists, vitamin K, and other
used in 5th place when there coagulants, accidental
are 6 digits in the code (unintentional)

27. Pain in Limb
• ICD-10-CM
• ICD-9-CM
• Over 30 Codes Choices!!!
▫ 729.5 Pain in limb ▫ Right, left or unspecified
▫ M79.60_ Pain in limb,
unspecified
Still need to indicate right or
left arm or leg
▫ M79.62_ Upper arm/axilla
▫ M79.63_ Forearm
▫ M79.64_ Hand/finger
▫ M79.65_ Thigh
▫ M79.66_ Pain, Lower leg
▫ M79.67_ Toe
▫ 6th digit 1-9 to indicate
laterality or specific digit

28. Ankle Sprain
• ICD-9-CM • ICD-10-CM
▫ 845.00 Sprains • Over 15 Code Choices!
and strains of ankle, ▫ Initial or subsequent encounter
(7th digit-A,D, or S)
unspecified site ▫ S93.409A Sprain of unspecified
ligament of unspecified ankle,
initial encounter
▫ S93.409D Sprain of unspecified
ligament of unspecified ankle,
subsequent encounter
▫ S93.409S Sprain of unspecified
ligament of unspecified ankle,
sequela

29. Pregnancy • ICD-10-CM
▫ 1st, 2nd or 3rd Trimester
▫ Z34.80 Encounter for supervision of
• ICD-9-CM other normal pregnancy, unspecified
▫ V22.1 Prenatal care, normal, trimester
other pregnancy ▫ Z34.81 Encounter for supervision of
other normal pregnancy, 1st trimester
▫ Z34.82 Encounter for supervision of
other normal pregnancy, 2nd trimester
▫ Z34.83 Encounter for supervision of
other normal pregnancy, 3rd trimester
▫ Z34.90 Encounter for supervision of
normal pregnancy, unspecified,
unspecified trimester
▫ Z34.91 Encounter for supervision of
normal pregnancy, unspecified,1st
trimester
▫ Z34.92 Encounter for supervision of
normal pregnancy, unspecified, 2nd
trimester
▫ Z34.93 Encounter for supervision of
normal pregnancy, unspecified, 3rd
trimester

30. Otitis Media
• ICD-10-CM
• ICD-9-CM ▫ Right, left or bilateral
▫ 381.00 Otitis media, acute ▫ Recurrent?
nonsuppurative, ▫ H65.191 Other acute nonsuppurative otitis
unspecified media, right ear
▫ H65.192 Other acute nonsuppurative otitis
media, left ear
▫ H65.193 Other acute nonsuppurative otitis
media, bilateral
▫ H65.194 Other acute nonsuppurative otitis
media, recurrent, right ear
▫ H65.195 Other acute nonsuppurative otitis
media, recurrent, left ear
▫ H65.196 Other acute nonsuppurative otitis
media, recurrent, bilateral
▫ H65.197 Other acute nonsuppurative otitis
media, recurrent, unspecified ear
▫ H65.199 Other acute nonsuppurative otitis
media, unspecified ear

31. Asthma
• ICD-10-CM
• ICD-9-CM ▫ Intermittent or persistent
▫ 493.90 Asthma, ▫ Mild, moderate or severe
▫ J45.20 Mild intermittent asthma,
unspecified uncomplicated
▫ J45.30 Mild persistent asthma,
uncomplicated
▫ J45.40 Moderate persistent,
uncomplicated
▫ J45.50 Severe persistent,
uncomplicated
▫ J45.909 Unspecified asthma,
uncomplicated
▫ J45.998 Other asthma

32. Ankle Fracture
• ICD-9-CM • ICD-10-CM
▫ 824.0 Fracture, medial • Over 12 Coding Choices
malleolus (closed) ▫ Traumatic or Pathologic
▫ Right or left
▫ Displaced or nondisplaced
▫ M84.47_ Pathological
fracture, ankle, foot and
toes (9 codes)
▫ S82.5_ Fracture of medial
malleolus (6 codes)

33. What Training Will
AAPC Offer?

34. 2011 2012 2013 2014
Onsite Provider Training X
Half-Day Workshop Throughout the X X
Country
Specialty-specific Distance Learning X X X
(eLearning)
Webinars X X X
Audio Conference Courses X X
X X X
National Conference Education Sessions
Proficiency Validation ** X X X
Regional Training X
**Proficiency validation will be taken online within the AAPC Member Area. The validation will be
composed of 75 questions, timed and open book. All certified coders are required to pass the validation by
September 30, 2014 to maintain certification. The proficiency validation may be taken twice for $60.

35. How Can Local Chapters Help?
▫ Some Examples might be ……
Work groups by specialty
Monthly speakers
List serve
Round table discussions
Networking events with other coding chapters
Track payer issues
Track vendor issues

36. Know Where to Go
Centers for Medicare and Medicaid Services www.cms.gov
American Academy of Professional Coders www.aapc.com
American Health Information Management Association www.ahima.org
American Academy of Family Physicians www.aafp.com
American Hospital Association www.aha.org
Workgroup for Electronic Data Interchange www.wedi.org
American Medical Billing Association www.amba.net
Healthcare Information and Management Systems Society www.himss.org
CMS information on 5010 transition:
http://www.cms.gov/Versions5010andD0/

37. Making Lemonade
• Embrace the change - its coming with you or
without you - no grace period!
• Huge book – small subset per specialty
• Develop crosswalks that are easy to use
• Plant seeds early - train later
• Provide general training and move to specific
training
• Begin implementation NOW!

38. Old Chinese Proverb
The Journey Is The Reward