What You Need to Know to be Ready for ICD-10

| | Utilization Review


By October 1, 2015, all “HIPAA-covered entities” must adopt the latest revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10). Whether you’re a physician, a Utilization Review Agent (URA), or a software vendor, the change will affect you and your organization.

Here’s what you need to know about the change from ICD-9 to ICD-10 and how to prepare.

How Will ICD-10 Impact Physicians?

Many physicians believe that ICD-10 is only a coding change, but ICD-10 will bring other changes, too. Physicians will have to adopt new diagnosis coding (ICD-10-CM) and procedure coding (ICD-10-PCS) systems, and making sure that all coders are properly trained is certainly an important concern.

Under ICD-10, physicians will have to document cases more thoroughly and with much greater specificity than ICD-9 required. Physicians will have to note information such as stages of healing and instances of care, along with other details. Coders will need the additional information to properly code, as ICD-10 raises the number of diagnosis codes to 140,000, from 17,000 under ICD-9.

How Will ICD-10 Impact URAs?

The sharp increase in diagnosis codes will have a noticeable impact on URAs. Insufficient and incorrect diagnosis codes and information are already the leading cause of claim rejection. With eight times the number of diagnosis codes, ICD-10 will create markedly more potential for providers to submit insufficient and incorrect diagnosis codes and inadequate documentation.

URAs will need to reconsider their operations and workflows to accommodate the new codes. Reviewers must familiarize themselves with documentation requirements under ICD-10. URAs will also have to consider how ICD-10 will affect the insurance companies they work with, with respect to the treatments authorized or denied based on some of the codes.

How Will ICD-10 Impact Software?

Systems built to accommodate the 17,000 ICD-9 codes and rules must be updated or replaced entirely. During the transition, firms will need software that can accommodate both ICD-9 and ICD-10.

Software vendors should offer support for implementing new or updated software by coordinating transition plans. UR software functionality and accuracy is crucial, and software must be tested rigorously to ensure that it meets the criteria. Some estimates indicate that sufficient testing could take up to 19 months.

Tips for Preparing for the Change

  • Buy a book: It will be impossible to memorize all of the ICD-10 codes. Consider buying and studying a text that compiles and explains the codes. The goal is not to memorize the codes, but to become familiar with their format.
  • Compare and contrast: Identify ICD-10 codes that most closely correspond to the ICD-9 codes you most commonly use. Study how they are similar and how they are different, and build a matrix to aid in training.
  • Use the resources: There are a variety of websites that can help train you and your staff.
  • Budget for potential problems: Set aside extra funding in case problems arise. Issues with processing claims could result in extended periods without payment, which may put your firm at risk.
  • Don’t expect another delay: The deadline for ICD-10 has been pushed back numerous times already. With more than a year to prepare, it makes sense to start getting ready now. In the unlikely event you get an extension, you’ll be well-positioned when the new requirements take effect.

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