Transitioning to ICD-10
The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions and procedures. While most countries already use the 10th revision of these codes (or ICD-10), the United States has yet to adopt this convention. The Centers for Medicare & Medicaid Services (CMS) is working closely with all industry stakeholders to provide support in transitioning to ICD-10 on Oct. 1, 2015.
ICD-9 is out of date.
ICD-9 is more than 35 years old and contains outdated, obsolete terms that are inconsistent with current medical practice. The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. ICD-10 provides room for code expansion, so providers can use codes more specific to patient diagnoses. The United States is the last major industrialized nation to make the switch to ICD-10.
ICD-10 codes will provide better support for patient care, and improve management, quality measurement, and analytics.
Since ICD-10 codes are more specific than ICD-9, doctors can capture much more information, meaning they can better understand important details about the patient’s health than with ICD-9-CM. This will:
- Improve coordination of a patient’s care across providers over time;
- Advance public health research, public health surveillance, and emergency response through detection of disease outbreaks and adverse drug events;
- Support innovative payment models that drive quality of care; and
- Enhance fraud detection efforts.
Physicians and physician specialty groups in the U. S. provided extensive input into the development and timing of implementation of ICD-10-CM to the Centers for Disease Control and Prevention.
In 2008, the U.S. Department of Health and Human Services (HHS) issued a proposed rule to transition to ICD-10 on Oct. 1, 2011. Stakeholders commented that they needed additional time to prepare for the transition. In the 2009 final rule, HHS established Oct. 1, 2013, as the date for the transition to give providers two additional years to prepare.
In 2012, as part of President Obama’s commitment to reducing regulatory burden, HHS moved the ICD-10 compliance date to Oct. 1, 2014, providing the industry with an additional year to work toward a successful transition. The Protecting Access to Medicare Act of 2014 (PAMA), which was enacted on April 1, 2014, prohibited the Secretary from adopting ICD-10 prior to Oct. 1, 2015.
Stopping or delaying the ICD-10 transition date would be costly to providers and all health care sectors.
The industry has invested significant resources toward the implementation of ICD-10. Many providers, including physicians, hospitals, and health plans, have already completed the necessary system changes to transition to ICD-10. Additional delays pose significant costs for providers who have updated their system.
CMS and many commercial health plans are unable to process claims for both ICD-9 and ICD-10 codes submitted for the same dates of service, so a “transition period” – in which providers could submit claims using either ICD-9 or ICD-10 – is not possible.
At the same time it is not feasible to skip directly to ICD-11 because ICD-10 is a foundational building block prior to moving to ICD-11. The earliest the ICD-11 code set will be released by the World Health Organization (WHO) is 2017. Several prominent industry groups, including the American Medical Association, have issued statements opposing transitioning directly to ICD-11 because of the complexity of the coding system and the best practice to implement ICD-10 to gain experience with that system first.
CMS has conducted extensive ICD-10 outreach, education, and testing, including use of social media, webinars, on-site training, educational articles, and national provider calls to help providers learn about ICD-10 and prepare for the transition.
CMS has developed multiple tools and resources that are available on the ICD-10 website (http://www.cms.gov/ICD10), including ICD-10 implementation guides, tools for small and rural providers, and general equivalency mappings (ICD-9 to ICD-10 crosswalk).
CMS has completed rigorous and comprehensive internal testing to ensure that CMS systems can accept and pay provider claims with ICD-10 codes on Oct. 1, 2015.
CMS has also been conducting external testing with Medicare fee-for-service providers, including two successful acknowledgement testing weeks in March and November 2014. Providers that participated in the testing received electronic acknowledgement confirming whether the submitted test claims were accepted or rejected. While providers, suppliers, billing companies, and clearinghouses can participate in acknowledgement testing at any time, CMS will be conducting the next two special acknowledgment testing periods in March and June 2015 to highlight the testing.
Separately, CMS is offering three end-to-end testing weeks for a sample of volunteer Medicare fee-for-service providers and suppliers leading up to Oct. 1, 2015. The testing weeks (Jan. 26 – Feb. 3, April 27 - May 1 and July 27-31) allow selected providers and suppliers to submit test claims to CMS with ICD-10 codes and receive a remittance advice explaining how the claims were processed. CMS is also working with state Medicaid agencies to conduct end-to-end testing.
Additional ideas on ways to ease this transition are welcome.