When billing for healthcare, diagnosis codes are part of the process, and there is a difference between the ICD-9 codes vs. ICD-10 codes.
What are the ICD-9 and ICD-10?
The International Classification of Diseases (9th revision and 10th revision) provides healthcare professionals with diagnosis codes that are necessary for diagnostic and billing purposes. “The transition to ICD-10 is required for everyone covered by…HIPAA”, which is the Health Insurance Portability Accountability Act.1 “A HIPAA covered entity” refers to “any organization…that directly handles Personal Health Information (PHI) or Personal Health Records (PHR).”2 The Centers for Medicare & Medicaid Services (CMS) offers introductory materials regarding the transition from ICD-9 to ICD-10.3 Converting to the ICD-10 “does not affect CPT coding for outpatient procedures and physician services”.4
According to the World Health Organization (WHO), the ICD is the “standard diagnostic tool for epidemiology, health management and clinical purposes”. It also includes features such as an “analysis of the general health situation of population groups”, and it can be used to “monitor the incidence and prevalence of diseases and other health problems”. The International Classification of Diseases is a tool utilized by health care providers, researchers, health coders, information technology workers, insurers, policy-makers, and patient organizations. The codes in the ICD are recorded on vital records, like death certificates and health records. The WHO Member States record national morbidity and mortality statistics from these records. Further, the “ICD is used for reimbursement and resource allocation decision-making by countries”. In May of 1990, the ICD-10 was released, and it has been in use by most member states since 1994. It had not been adopted by the US, however, at that time. According to the WHO, the ICD is going to be revised again, and the ICD-11 is scheduled for release in 2018.5
ICD-10 Transition in the US
In 2009, HHS, the US Department of Health and Human Services, had published a rule that the ICD-10 would be adopted in the US in October of 2013 (after industry representatives requested a push back from 2011). Contributing to the delay, the industry had been having concerns about the “costs falling on providers and many of the benefits accruing to public health entities and health plans”. As a result, “the Centers for Medicare & Medicaid Services (CMS)” responded by “granting an additional one year for implementation” until 2014, as a compromise. The US was not prepared for that deadline, either, so the implementation was changed to October 2015. According to Stanley Nachimson, the founder of Nachimson Advisors, LLC, “We did a poor job of education, preparation, and implementation.” The delays, however, gave the industry (providers, vendors, and plans) time to focus on the transition, and prepare for the implementation. 6
In the United States, the term “ICD-10” usually refers to the “ICD-10-CM” (for clinical modification). The ICD-9-CM had problems in that there was no way to expand the code set. Each category of three digits could only have a total of 10 subcategories. As medicine achieved new discoveries, there was no way to assign new numbers to the new diagnoses. With the more detailed codes of the ICD-10-CM, it is believed there will be a “better analysis of disease patterns and treatment outcomes advancing medical care” and claims submissions will be streamlined, since the payers will understand the details of the initial claim much better.7 The ICD-9 has 13,000 codes. It had been used in US since 1979. The codes are 3-5 numerical digits. Chiropractors typically used 30-40 of these codes, and they used about half of those regularly. Diagnosis “cheat sheets” are used by medical offices because doctors “see a lot of the same things over and over” and use some codes regularly. “5% of the codes represent 70% of claims” in medicine, but chiropractic is usually focused on certain things related to the neuromuscular skeletal system. There are 68,000 codes, but chiropractors will use maybe 150. The codes are 3-7 characters, with an alpha (letter) start. As of October 1, 2015, the ICD-10 is being used in the US. It is important to know that services performed on 10/1/15 or later need to use ICD-10 codes. Services performed on 9/30/15 or before must use ICD-9 codes. The diagnosis codes are not based on when the bills are submitted, but rather the date when services were performed. Chiropractors can work on their own to convert their cheat sheet into the ICD-10 codes, but there are tools available to make the process easier.8
The Digital Coding Manual by HJ Ross is a system designed to help chiropractors find the information that they need. Their system has a search feature to quickly convert codes. The ICD-10 for chiropractic care breaks out the old ICD-9 diagnoses into more specific codes. For example, if a patient has “multiple disk bulges”, the chiropractic ICD 10 codes will reflect that more specifically, and that will impact care by helping to show the multiple areas of dysfunction. The more complicated part comes in cases like sciatica, for example, which will have several new codes that allow for not only the area of trouble, but whether or not it is on the right or the left side. ICD-10 also differentiates between sprains and strains, as another example. Even though there are more ICD 10 chiropractic codes, they are clear in their specificity. In chiropractic, this is useful in billing because the codes point to specific regions, and therefore can help justify why billing for a particular condition is needed. Chiropractors can also choose to map codes on their own, but some ICD 10 codes for chiropractic are not 1:1, but 1:10, for example, and others may not have a clear mapping from ICD 9 codes for chiropractic care to ICD-10. A computerized system, like the one HJ Ross provides, may make the conversion process easier, and chiropractors can subscribe online to their Digital Coding Manual. The advantage of ICD-10 over ICD-9 is that instead of a “basic diagnosis” that may make it seem like there is “lesser necessity” for services, the ICD-10 can provide a “specific diagnosis…and accurate description”, educating the insurance carrier about the patient’s needed “level of care”.9