ICD-10 Implementation	
• Pat Brooks, RHIA
• Patricia.brooks2@cms.hhs.gov 
• Senior Technical Advisor
• Hospital and Ambulatory Policy Group, CMM, CMS

ICD-10 Final Rule
• Published January 16, 2009 
– CMS-0013-F
– http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf 
• October 1, 2013 implementation
– ICD-10-CM
– ICD-10-PCS

ICD-10 Final Rule Issues
• Implementation date October 1, 2013
– Single date for all users
• Date of service for ambulatory & physician reporting
• Date of discharge for inpatient settings
– ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013
– ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time

ICD-10 Final Rule Issues
• Outreach and education
– CMS worked collaboratively with AHA, AHIMA, and CDC (Cooperating Parties) on outreach materials
– Educational resources at http://www.cms.hhs.gov/ICD10/05_Educational_Resources.asp#TopOfPage 

ICD-10 Final Rule Issues
• Outreach and education
– Series of ICD-10 Outreach calls prior to final rule
– Information on calls posted at http://www.cms.hhs.gov/ICD10/07_Sponsored_Calls.asp#TopOfPage
• Transcripts of each call
• Slides used in calls

ICD-10 Final Rule Issues
• Outreach and education
– Plan additional outreach efforts through collaboration with Cooperating Parties
– Information on future educational outreach will be posted at http://www.cms.hhs.gov/ICD10/05_Educational_Resources.asp#TopOfPage 
– AHA, AHIMA, and others will also provide more detailed outreach and education resources

ICD-10 Final Rule Issues
• ICD-10 annual updates
– Coordination & Maintenance Committee will continue to discuss updates to ICD-9-CM, ICD-10-CM, & 
ICD-10-PCS
– Annual updates on CMS & CDC homepages
– Number of total codes changes with updates

ICD-10 Final Rule Issues
• ICD-10 annual updates
– New name – ICD-10 Coordination & Maintenance Committee upon implementation
– Need to discuss any need to freeze coding systems prior to implementation
• Will be agenda item for September 16-17, 2009
– Should ICD-10 and/or ICD-9-CM be frozen prior to implementation?
– When should the freeze begin?

ICD-10 Final Rule Issues
• Resources available on CMS & CDC websites
– Complete ICD-10-CM and PCS systems including guidelines
– General Equivalence Mappings (GEMs) between ICD-9-CM and ICD-10 (both ways)
– Users guide for GEMS
– Abbreviated Reimbursement Mappings 
– Development of ICD-10 version of MS-DRGs

Complete versions of ICD-10
• ICD-10-CM (diagnoses)
– http://www.cms.hhs.gov/ICD10/02m_2009_ICD_10_CM.asp#TopOfPage 
• ICD-10-PCS (procedures)
– http://www.cms.hhs.gov/ICD10/01m_2009_ICD10PCS.asp#TopOfPage 

ICD-9-CM Users
• ICD-9-CM Diagnoses – used by all types of providers
– ICD-10-CM will replace
• ICD-9-CM Procedures – used only by inpatient hospitals
– ICD-10-PCS will replace
• Current Procedural Terminology (CPT) & HCPCS– used for all ambulatory and physician procedure reporting
– Not being replaced by ICD-10

ICD-9-CM is Outdated
• 30 years old – technology has changed
• Many categories full
• Not descriptive enough

Countries Using ICD-10 For Reimbursement or Case Mix
• United Kingdom (1995)
• Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) (1994 – 1997)
• France (1997)
• Australia (1998)
• Belgium (1999)
• Germany (2000)
• Canada (2001)

Structural Differences - Diagnoses
• ICD-9-CM has 3 – 5 digits
• Chapters 1 – 17: all characters are numeric
• Supplemental chapters: first digit is alpha (E or V), remainder are numeric
• Examples: 
– 496  Chronic airway obstruction not elsewhere classified (NEC)
– 511.9  Unspecified pleural effusion
– V02.61  Hepatitis B carrier

Structural Differences - Diagnoses
• ICD-10-CM has 3 – 7 digits
• Digit 1 is alpha (A – Z, not case sensitive)
• Digit 2 is numeric
• Digit 3 is alpha (not case sensitive) or numeric
• Digits 4 – 7 are alpha (not case sensitive) or numeric
– A66  Yaws
– A69.20  Lyme disease, unspecified
– O9A.311  Physical abuse complicating pregnancy, first trimester
– S42.001A  Fracture of unspecified part of right clavicle, initial encounter for closed fracture

Structural Differences - Procedures
• ICD-9-CM has 3 – 4 digits
• All 4 digits are numeric
– 43.5  Partial gastrectomy with anastomosis to esophagus
– 44.42  Suture of duodenal ulcer site

Structural Differences - Procedures
• ICD-10-PCS has 7 digits
• Each can be either alpha (not case sensitive) or numeric
– Numbers 0 – 9 are used
– Letters O and I are not used to avoid confusion with numbers 0 and 1
• Examples
– OFB03ZX Excision of liver, percutaneous approach, diagnostic
– 0DQ10ZZ  Repair, upper esophagus, open approach

Number of Codes – 2009
• Diagnoses 
– ICD-9-CM		14,025
– ICD-10-CM		68,069

• Procedures
– ICD-9-CM		 3,824
– ICD-10-PCS		72,589	
ICD-9/ICD-10 Code Mappings

• General equivalence mappings (GEMS)
• Designed to aid in converting applications and systems from I-9 to I-10
• Bi-directional mappings
• For “finding and replacing” codes or lists of codes

Bi-directional Mappings
Use of GEMs to convert payment system
• CMS illustrated use of GEMS by developing ICD-10 version of MS-DRGs
• Began with digestive MS-DRGs, Major Diagnostic Category (MDC 6)
• Presented results at September 24, 2008 ICD-9-CM Coordination & Maintenance Committee meeting
• Will complete all MS-DRGS by October 1, 2009

MS-DRG Conversion Goals
• Coded in I-9 or I-10, the same patient is assigned to the same MS-DRG 
• Clinically equivalent
• Definitions manual has familiar look and feel

MDC 6, DISEASES & DISORDERS OF THE DIGESTIVE SYSTEM

A00* Cholera (3 codes)
A020 Salmonella enteritis
A03* Shigellosis (6 codes)
A04* Other bacterial intestinal infections (10 codes)
A050 Foodborne staphylococcal intoxication
A052 Foodborne Clostridium perfringens [Clostridium welchii] intoxication
A053 Foodborne Vibrio parahaemolyticus intoxication
A054 Foodborne Bacillus cereus intoxication
A055 Foodborne Vibrio vulnificus intoxication
A058 Other specified bacterial foodborne intoxications
A059 Bacterial foodborne intoxication, unspecified

Find and Replace
Diagnosis Codes
DRG385 INFLAMMATORY BOWEL DISEASE W MCC
DRG386 INFLAMMATORY BOWEL DISEASE W CC
DRG387 INFLAMMATORY BOWEL DISEASE W/O CC/MCC

PRINCIPAL DIAGNOSIS
5550 Reg enteritis, sm intest
5551 Reg enteritis, lg intest
5552 Reg enterit sm/lg intest
5559 Regional enteritis NOS
DRG 385 Inflammatory bowel disease w MCC
DRG 386 Inflammatory bowel disease w CC
DRG 387 Inflammatory bowel disease w/o CC/MCC

Principal Diagnosis
K5000 Crohn's disease of small intestine without complications
K50011 Crohn's disease of small intestine with rectal bleeding
K50012 Crohn's disease of small intestine with intestinal obstruction
K50013 Crohn's disease of small intestine with fistula
K50014 Crohn's disease of small intestine with abscess
K50018 Crohn's disease of small intestine with other complication
K50019 Crohn's disease of small intestine with unspecified complications
K5010 Crohn's disease of large intestine without complications
K50111 Crohn's disease of large intestine with rectal bleeding
K50112 Crohn's disease of large intestine with intestinal obstruction
K50113 Crohn's disease of large intestine with fistula
K50114 Crohn's disease of large intestine with abscess
K50118 Crohn's disease of large intestine with other complication
K50119 Crohn's disease of large intestine with unspecified complications
K5080 Crohn's disease of both small and large intestine without complications
K50811 Crohn's disease of both small and large intestine with rectal bleeding
K50812 Crohn's disease of both small and large intestine with intestinal obstruction
K50813 Crohn's disease of both small and large intestine with fistula
K50814 Crohn's disease of both small and large intestine with abscess
K50818 Crohn's disease of both small and large intestine with other complication

Find and Replace
Procedure Codes
DRG335 PERITONEAL ADHESIOLYSIS W MCC
DRG336 PERITONEAL ADHESIOLYSIS W CC
DRG337 PERITONEAL ADHESIOLYSIS W/O CC/MCC

OPERATING ROOM PROCEDURES
5451 Lap periton adhesiolysis
5459 Oth periton adhesiolysis
DRG 335 Peritoneal adhesiolysis w MCC
DRG 336 Peritoneal adhesiolysis w CC
DRG 337 Peritoneal adhesiolysis w/o CC/MCC

Operating Room Procedures: lysis
0DN80ZZ Release Small Intestine, Open Approach
0DN82ZZ Release Small Intestine, Open Endoscopic Approach
0DN83ZZ Release Small Intestine, Percutaneous Approach
0DN84ZZ Release Small Intestine, Percutaneous Endoscopic Approach
0DN90ZZ Release Duodenum, Open Approach
0DN92ZZ Release Duodenum, Open Endoscopic Approach
0DN93ZZ Release Duodenum, Percutaneous Approach
0DN94ZZ Release Duodenum, Percutaneous Endoscopic Approach
0DNA0ZZ Release Jejunum, Open Approach
0DNA2ZZ Release Jejunum, Open Endoscopic Approach
0DNA3ZZ Release Jejunum, Percutaneous Approach
0DNA4ZZ Release Jejunum, Percutaneous Endoscopic Approach
0DNB0ZZ Release Ileum, Open Approach
0DNB2ZZ Release Ileum, Open Endoscopic Approach
0DNB3ZZ Release Ileum, Percutaneous Approach
0DNB4ZZ Release Ileum, Percutaneous Endoscopic Approach
0DNE0ZZ Release Large Intestine, Open Approach
0DNE2ZZ Release Large Intestine, Open Endoscopic Approach

MS-DRGs Conversion Summary
• The GEMs produce 95% of the MDC 6 mapping without any need for review
• The remaining 5% is based on MDC 6
– Need for review of the remaining MDCs is expected to steadily decrease
– As the rules derived for MDC 6 are applied to the remaining MDCs, fewer codes will need clinical review

Overly Broad I-9 Procedure Codes
• ~200 overly broad I-9 procedure codes identified
• Should an I-9 procedure code be replaced with all associated PCS codes everywhere an I-9 code is listed?

Examples of 
Overly Broad I-9 Codes

I-9		Description
92.27	Radioactive elem implant
86.09	Skin & subq incision NEC
83.82	Muscle or fascia graft
81.96	Other repair of joint
80.19	Other arthrotomy NEC 
77.19	Bone incis w/o div NEC 
39.50	Angio oth non-coronary
39.31	Suture of artery
39.29	Vasc shunt & bypass NEC
38.21	Blood vessel biopsy
01.24	Other craniotomy
04.04	Peripheral nerve incis NEC

Solution for I-9 Overly Broad Procedure Codes
• Limit the assignment of PCS codes associated with overly broad I-9 codes to anatomic sites corresponding to each MDC

MDC 6 Example: 
DRGs 356, 357, 358 Other Digestive System O.R. Procedures 
92.27 Implantation or Insertion of Radioactive Elements 
• For procedure 92.27, only 10 of the 261 PCS codes are assigned to MDC 6
I-9 Code Conflicts 
Conflict: Where an I-10 code is assigned to more than one I-9 code and the I-9 codes are assigned to different MS-DRGs

I09.89 Other specified 	rheumatic heart 	diseases
		Rheumatic disease of 	pulmonary valve

398.99 	Other rheumatic heart 	diseases
	in MDC 5 DRG 314,315,316 
	Other circulatory system diagnoses 
397.1 	Rheumatic diseases of pulmonary valve
	in MDC 5 DRG 306,307 
	Cardiac congenital & valvular disorders

Use of GEMs to convert payment system
• Will discuss progress at future C&M meetings
– September 16, 17, 2009
– Register for C&M at http://www.cms.hhs.gov/apps/events/ 
• Complete ICD-10 Grouper by October 2009, post by the end of 2009 on ICD-10 website
• Final Grouper logic subject to rulemaking

The GEMs and 
the Reimbursement Mapping
• The GEMs are designed to aid in converting applications and systems from I-9 to I-10
• Some payers found the detail daunting
• Developed streamlined Reimbursement Mapping (one to one best map) 
• The reimbursement mappings would assist in a more simple conversion of codes for reimbursement purposes

Development of 
Reimbursement Mapping
• Start with the I-10 to I-9 GEM
• Where an I-10 code is translated to one I-9 code, no additional review is necessary
– 95% percent of the I-10 codes is translated to a single I-9 code
– Many 1-10 codes are translated to the same I-9 code
• Where an I-10 code is translated to more than one I-9 code, historical I-9 code frequency data are used to determine the most commonly used I-9 code among the I-9 code alternatives
– Medpar and California (for newborn and OB codes) data were used
– In the vast majority of cases there is a clear dominant code in terms of frequency
– In rare cases, clinical review is needed to make the final choice

Use of Mappings	
• The GEMs and Reimbursement mappings were designed to be used by all providers, payers, and data users
• They are tools to assist in converting data
• They are publicly available on the CMS & CDC websites
• We will continue to update and maintain the mappings

ICD-10 Updates
• Posted on CMS ICD-10 website http://www.cms.hhs.gov/ICD10/ 
– 2009 Diagnosis GEMs and user guide
– 2009 Procedure GEMs and user guide
– 2009 Reimbursement mapping 
– ICD-10 Digestive System MS-DRGs
– 2009 version of ICD-10-CM and PCS codes and official coding guidelines


