ICD-10 and Quality Measures
On October 1, 2015, the U.S. health care system transitioned the way patient claims and diagnoses and inpatient hospital procedures are coded from the International Classification of Disease, 9th Revision, Clinical Modification, Volumes 1 and 2 (diagnoses), and 3 (procedures) (ICD-9-CM) to the International Classification of Disease, 10th Revision, Procedure Coding System (ICD-10-PCS) for inpatient procedure coding (collectively, ICD-10), which sets the stage for meaningful improvements in public health.
The migration of the healthcare industry to ICD-10 impacts the calculation of claims-based quality measures as the reporting periods include data on or after October 1, 2015. CMS has anticipated this migration and claims-based measures have been cross-walked/mapped to ICD-10. CMS prepared for this transition by carefully evaluating the revised measures to ensure that the validity of the measures are maintained.
This ICD-10 and Quality Measures website is dedicated to assisting quality measure stakeholders by sharing information related to ICD-10 for quality measure development purposes only. For full ICD-10 information, see the main CMS ICD-10 website. The ICD-10 and Quality Measures Frequently Asked Questions (FAQs) (PDF) [last updated May 30, 2017] is another valuable resource that provides in-depth information related to ICD-10 and quality measures in addition to answering common questions.
Please note for some programs, the ICD-10 code lists are located in the Specification Manuals.
Important to the development of Clinical Quality Measures are the use of value sets. Value sets contain lists of codes and corresponding used by developers and implementers to accurately capture patient data in the EHR system. CMS has published Value Set Guidance that will help developers in the design and maintenance of value sets, including areas of naming, description, and harmonization. Value set guidance can be viewed under the Resources menu of the Electronic Clinical Quality Improvement (eCQI) Resource Center
Ambulatory Surgical Centers
ICD-10 codes included in the clinical quality measures for the Ambulatory Surgical Center Quality Reporting Program can be found on the QualityNet Ambulatory Surgical Center Quality Reporting Program Quality Measures Specifications Manual webpage. Click on the specific manual version of interest, and ICD-10 codes are located within the individual measure information forms of the Specifications Manual.
ICD-10 codes included in the chart-abstracted clinical process of care measures for the Hospital Inpatient Quality Reporting Program can be found on the QualityNet Specifications Manual for National Hospital Inpatient Quality Measures webpage. Click on the specific manual version of interest, and ICD-10 code tables are located in Appendix A of the Specifications Manual.
ICD-10 codes included in electronic clinical quality measures (eCQMs) for Eligible Hospitals and Critical Access Hospitals can be found in the value sets located in the Value Set Authority Center (VSAC) provided by the National Library of Medicine. In order to access the VSAC, you must have or request a free Unified Medical Language System® Metathesaurus License. We recommend accessing the value sets for all Eligible Hospital measures by clicking the “Download” tab and accessing the Downloadable Resources Table for the corresponding reporting period. Once a table is downloaded, ICD-10 codes are located in the “Code” column.Other Inpatient Quality Measures
More information regarding ICD-10 codes included in other inpatient hospital quality measures, such as the Medicare Spending per Beneficiary Measures, the CDC National Healthcare Safety Network Surgical Site Infection Measures, the CMS Outcome and Payment Measures, and the Patient Safety and Adverse Events (PSI 90) Composite Measure, are available in the ICD-10 and Quality Measures Frequently Asked Questions (FAQs) (PDF) last updated May 30,2017].
ICD-10 codes included in the chart-abstracted measures for the Hospital Outpatient Quality Reporting Program can be found on the QualityNet Hospital Outpatient Quality Reporting Specifications Manual webpage. Click on the specific manual version of interest, and ICD-10 code tables are located in Appendix A of the Specifications Manual.
Physician Quality Reporting System (PQRS)
ICD-10 codes included in the 2016 individual claims and registry measures, as well as the 2016 measure groups for the Physician Quality Reporting System (PQRS), can be found on the Physicians Quality Reporting System Measures Codes webpage. For 2016 individual claims and registry measures, click on the 2016 PQRS Individual Claims Registry Measure Specifications zip file or the 2016 Physician Quality Reporting (PQRS) Single Source Code Master Excel file. Each measure specification document includes the ICD-10 codes relevant to that measure and the single source code master Excel file is a listing of all coding applicable for these measures in a searchable format. For 2016 PQRS measures groups, click on the 2016 PQRS Measures Groups Specifications Supporting Documents zip file. This file includes the measures group specification manual and a measures group single source code master Excel file, both listing applicable ICD-10 coding for each of the measures groups.
ICD-10 codes included in the 2016 Group Practice Reporting Option (GPRO) Web Interface measures can be found on the Physicians Quality Reporting System GPRO Web Interface webpage. The ICD-10 codes relevant for each measure can be found in the Downloadable Resource Tables with each of the 2016 GPRO Web Interface Supporting Documents. ICD-10 codes included in eCQM electronic measures (eCQM Library webpage) can be found within the Value Set Authority Center (VSAC). For general information on the PQRS measures, visit the CMS PQRS page.
Information on the ICD-10 codes included in the clinical quality measures for the Home Health Quality Reporting Program can be found on the Home Health Quality Measures page. Measure specifications, which include both ICD-9 and ICD-10 codes, are available in the “Downloads” section, along with information on the risk-adjustment models for all outcome measures. Visit the Home Health Quality Measures page for further information.
For questions about coding:
The Centers for Medicare & Medicaid Services does not provide specific coding guidance. Several resources are listed below to assist you:
- The ICD-10 code lookup tool: /medicare-coverage-database/staticpages/icd-10-code-lookup.aspx
- ICD-10 coding resources for Providers: /Medicare/Coding/ICD10/ProviderResources
- Requests for updates to the diagnosis and procedure code sets are discussed at the ICD-10 Coordination and Maintenance Committee meetings: /Medicare/Coding/ICD10/ICD-10-Coordination-and-Maintenance-Committee-Meetings
- For specific coding questions: Specific coding questions should be submitted to the American Hospital Association (the official US clearinghouse on medical coding) via http://www.codingclinicadvisor.com/
- AHIMA is now also providing coding advice for a fee through their Code Check service. You can learn more information at this link: http://www.ahima.org/topics/codecheck
For ICD-10 CM and GEMs information: /Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs
For ICD-10 CM diagnosis code requests involving new codes, updates or revisions to the code set, please contact: nchsicd10CM@cdc.gov
ICD-10 CM Guidelines can be found at the following website: http://www.cdc.gov/nchs/icd/icd10cm.htm
For ICD-10 PCS and GEMs information: /Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs
For ICD-10 PCS procedure code requests involving new codes, updates or revisions to the code set, please contact: ICDProcedureCodeRequest@cms.hhs.gov
2017 updates for ICD-10 PCS procedure codes: /Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs
FY 2017 ICD10 and Quality Measures FAQs (PDF)