On Oct. 1, 2015, the healthcare diagnostic process will undergo a fundamental shift. Starting that day, the ICD-9 (International Classification of Diseases, 9th Edition) code sets used to report medical diagnoses and inpatient procedures will be replaced by the ICD-10 code set.  Any organizations who fail to comply will be unable to bill for any services provided after that date, which could severely impact their cash flow and their ability to deliver care to the country’s most vulnerable populations.

Five Frequently Asked Questions About ICD-10:

  1. Are any healthcare providers exempt from the ICD-10 mandate?
    If your organization currently submits bills using ICD-9 codes, it will be required to submit bills using ICD-10 codes for services rendered on and after Oct. 1, 2015. If you are an inpatient facility, ICD-10 is required for all claims with a discharge or thru date of Oct. 1, 2015 or later.
  2. Can I submit bills using ICD-10 codes early?
    The mandate does not allow for early submission of ICD-10 or continued submission of ICD-9 codes. As per the federal mandate, if an organization submits claims for services rendered prior to Oct. 1, 2015 using ICD-10 codes, those claims will be denied. Similarly, if an organization submits claims using ICD-9 codes for services rendered after Oct. 1, 2015, those claims will be denied.
  3. I work in a behavioral health outpatient facility and we don’t update client diagnosis on every visit. How do I manage outpatient episodes that span the cutover time?
    This depends on what an organization’s electronic solution supports. If one’s EHR supports dual coding – capturing both ICD-9 and ICD-10 – this is recommended. In this case, claims would be submitted using either ICD-9 or ICD-10 depending on date of service. If the service was rendered after Oct.1, 2015, the claim would be submitted with the ICD-10 code. Services rendered prior to then would be submitted with an ICD-9 code. If this is not an option, then 1) On Oct. 1, 2015, close out all episodes and create new ones with ICD-10 diagnoses for any clients who utilize services after that date or 2) update all clients’ diagnoses with new ICD-10 codes/diagnoses with an effective date of Oct. 1, 2015.
  4. What impact does DSM-5 have on billing? DSM-5 isn’t a billing code set and cannot used for claim submission. In fact, the DSM-5 is not a code set at all.  The manual provides diagnostic terms and criteria that reference the ICD-9 or ICD-10 code to use on the claim.  Payors may choose to only reimburse for ICD-9 or ICD-10 codes that are explicitly listed in the DSM-5 manual. Alternatively, they may enforce this on subsequent audits.  In this scenario, they would look to ensure that the clinical documentation matches the terms and criteria that are explicitly listed in the DSM-5 manual.
  1. If ICD-10 procedure codes are required, does that mean we won’t use CPT codes anymore?   The ICD-10 mandate only impacts inpatient procedures.  It does not impact the CPT or HCPCS codes currently used for outpatient services or inpatient physician services.  Only those organizations who are currently submitting claims using ICD-9 procedure codes will be required to move to ICD-10-PCS for inpatient procedures. In this scenario, ICD-9 vs. ICD-10 will be dependent on the discharge or thru date of the inpatient encounter, not the date the procedure was rendered.

A growing number of Netsmart clients are currently ICD-10 ready. Perhaps their stories can help you!