Ready or Not, Here it Comes: Welcome to the New World of ICD-10!

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions, Helios


changesAlthough the vast majority of the medical leading countries around the world have been working with ICD-10 codes for many years, the US will finally enter the picture and join those which have adopted ICD-10 for diagnosis, treatment, billing, and reporting medical information starting October 1, 2015. The Center for Medicare and Medicaid Services (CMS) has been leading the efforts for quite some time. After years of roadblocks, hesitation from the medical community, and the challenge of the costs in adopting a new system for all involved, public and private systems, ICD-10 will become a reality for all using and communicating medical information October 1, 2015. Although only required for providers when dealing with Medicare and Medicaid, the reality is that both of these systems have such a large impact on all other private medical processes and systems, that virtually all other private medical payers, insurers, providers, and users will also adopt ICD-10 as the universal method of communicating medical information. My hope here is to provide you with a basic introduction to ICD-10, including how we got here, basics about the codes, and some of the expected benefits.

ICD-10 Implementation History

In the U.S., the transition to ICD-10 has been a 7 year project. On August 22, 2008, the US Department of Health and Human Services (HHS) proposed HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt ICD–10–CM and ICD–10–PCS. On January 16, 2009, HHS published a final rule in which the Secretary adopted ICD–10 as the HIPAA standard code set to replace ICD–9–CM. The 2009 ICD–10 final rule established an October 1, 2013 compliance date for ICD–10. As a result of industry concerns, in 2012, HHS published an ICD–10 delay final rule in which the compliance date for ICD–10 was delayed from October 1, 2013 to October 1, 2014. However, before the effective date of this last delay, Congress enacted the Protecting Access to Medicare Act of 2014 (PAMA) on April 1, 2014, requiring the Secretary of HHS to adopt ICD–10 no sooner than October 1, 2015. As a result, on August 4, 2014, HHS published its final rule implementing section 212 of PAMA by establishing October 1, 2015, as the new ICD–10 compliance date.

What is ICD-10?

Developed by the World Health Organization (WHO) as the International Classification of Diseases (ICD), ICD became a method of coding medical patients’ state of health and institutional procedures. ICD-9, the version in use prior to the conversion to ICD-10, was adopted by the WHO in 1979. ICD-10 was adopted by the WHO in 1990. Countries using ICD-10 for reimbursement or case mix include the United Kingdom (1995), Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) (1994 –1997), France (1997), Australia (1998), Belgium (1999), Germany (2000), and Canada (2001). Although certainly late as compared to these countries, taking so long to adopt ICD-10 has given us the ability to study and examine how other countries have struggled through and been able to meet ICD-10 challenges. As a result, our version of ICD-10 is different than the rest of the world. Ours includes ICD-10-CM and ICD-10-PCS.

ICD-10-CM and ICD-10-PCS

Although there is generally one version of ICD-10 used throughout the world, in the U.S., ICD-10 includes two separate versions: ICD-10-CM, which defines clinical modification in all health care settings of the WHO standard for diagnoses, and ICD-10-PCS, which is the inpatient procedures coding system for hospital settings developed and maintained by CMS. ICD-10-CM and PCS apply to all HIPAA-covered entities, and will provide more information per code, will provide better support for care management, quality measurement, and analytics, and will significantly improve our ultimate ability to understand risk and severity. In a time and era in which data is king, ICD-10 will allow all of us who collect such information to have greater detail about anything and everything medical.

ICD-10-CM Chapters and Categories

ICD-10-CMs are broken down into 21 chapters. Each chapter covers specific categories:

  • Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
  • Chapter 2: Neoplasms (C00-D49)
  • Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
  • Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
  • Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)
  • Chapter 6: Diseases of the Nervous System (G00-G99)
  • Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
  • Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)
  • Chapter 9: Diseases of the Circulatory System (I00-I99)
  • Chapter 10: Diseases of the Respiratory System (J00-J99)
  • Chapter 11: Diseases of the Digestive System (K00-K95)
  • Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)
  • Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
  • Chapter 14: Diseases of Genitourinary System (N00-N99)
  • Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
  • Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)
  • Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
  • Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
  • Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)
  • Chapter 20: External Causes of Morbidity (V00-Y99)
  • Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

ICD-10-PCS: Procedure Coding System

ICD-10-PCS are broken down into 16 categories. Each covers the following:

  • 0: Medical and Surgical
  • 1: Obstetrics
  • 2: Placement
  • 3: Administration
  • 4: Measurement and Monitoring
  • 5: Extracorporeal Assistance and Performance
  • 6: Extracorporeal Therapies
  • 7: Osteopathic
  • 8: Other Procedures
  • 9: Chiropractic
  • B: Imaging
  • C: Nuclear Medicine
  • D: Radiation Therapy
  • F: Physical Rehabilitation and Diagnostic Audiology
  • G: Mental Health
  • H: Substance Abuse Treatment

Getting Ready for ICD-10

On October 1, 2015, physicians, clinics, hospitals, diagnostic facilities, and all other providers must start using ICD-10 codes for services provided on or after October 1, 2015. A major difference between ICD-9 and ICD-10 codes include the fact that ICD-9-CM diagnosis codes use 3 to 5 digits, while ICD-10-CM codes use 5 to 7 digits. This change alone will allow for greater detail and significantly more codes that were badly needed to truly explain today’s medical care and treatment. ICD-9-CM procedure codes used 3 to 4 numeric digits, while ICD-10-PCS codes use 7 alphanumeric digits. As a result, unlike ICD-9, which had essentially run out of room for new codes and no longer had the ability to provide necessary detail, ICD-10 significantly expands the number of codes and details of each code for all conditions.

Why Transition to ICD-10

It is undeniable that ICD-10 better reflects current medical practice, terminology, and procedures. ICD-10 captures more specific data from clinical documentation than ICD-9. Fractures, for example, captures left vs. right side of body, initial vs. subsequent encounter, routine vs. delayed healing, and nonunion vs. malunion. ICD-10-PCS provides detailed information on procedures and distinct codes for all types of devices. As a result, the detail captured by ICD-10 can facilitate patient care coordination across settings, and improve public health reporting and tracking. In addition, while ICD-9 is running out of capacity and cannot continue to accommodate additional codes to reflect new diagnoses and procedures, the ICD-10 structure will be able to accommodate thousands of new codes for years to come.

Benefits of ICD-10

It is also clear that ICD–10 will provide greater specificity of diagnosis-related groups, will improve quality measurement and reporting capabilities, will improve tracking of illnesses, and reflect greater accuracy of reimbursement for medical services. We are convinced that ICD–10’s granularity will also improve data capture and analytics of public health surveillance and reporting, national quality reporting, research and data analysis, and provide detailed data to inform health care delivery and health policy decisions. It is universally accepted that the specificity of ICD-10 will improve the quality of healthcare we will all receive as ICD–10 includes significant improvements over ICD–9 in coding primary care encounters, external causes of injury, mental disorders, and preventive health, just to name a few.

ICD-10 Impacting Workers Compensation Public Policy Changes

As states have begun to prepare for ICD-10, numerous workers’ compensation jurisdictions have adopted changes to billing (electronic and paper) rules/requirements, placing these rules in alignment with federal requirements utilizing ICD-10 codes. States implementing ICD-10 billing requirements include CA, CO, FL, GA, NY, NC, OH, and TX. Similar to billing, WC jurisdictions have also adopted changes to their EDI/State Reporting rules and requirements also aligning them with usage of the ICD-10 codes. States implementing ICD-10 state reporting requirements include CA, OR, TX, and FL. National billing and state reporting standards, such as NCPDP and IAIABC have adopted the “most current” federal ICD requirements into their standards. States adopting drug formularies and nationally-recognized treatment guidelines also utilize ICD diagnosis and procedure codes for treatment compliance.

ICD-10 Conversion and Mandatory Insurer Reporting

ICD-10 also affects MSP, especially mandatory insurer reporting. For submissions prior to October 1, 2015, use of ICD-9-CM diagnosis codes is mandatory. For submissions beginning October 1, 2015, ICD-10-CM diagnosis codes will be required on all production Claim Input Files (CIP) and Direct Data Entry (DDE) add and update records with a CMS DOI on or after October 1, 2015. For submissions beginning October 1, 2015, either ICD-9-CM or ICD-10-CM diagnosis codes will be accepted on all add and update records with a CMS DOI prior to October 1, 2015. However, each record can only contain either all ICD-9-CM or all ICD-10-CM codes. RREs may not submit a combination of ICD-9-CM and ICD-10-CM diagnosis codes on one single record. RREs will not be required to convert or crosswalk ICD-9-CM codes submitted on previously accepted records to ICD-10-CM codes when submitting subsequent updates to those records.

More Effects of ICD-9 and ICD-10 on Medicare Secondary Payer

The effects of these changes don’t stop at MIR. Effective January 1, 2016, CMS has already indicated it will add an additional limitation to Medicare claims payments where insurers or workers’ compensation entities have reported to CMS that they have Ongoing Responsibility for Medicals (ORM). In situations where an insurer or workers’ compensation entity has reported to CMS that it has ongoing responsibility for medicals for specific care, CMS’ claims processing contractors will use the information provided by the insurer or workers’ compensation entity to determine whether Medicare is able to make payment for those claims. CMS has made it clear that insurers and workers’ compensation entities that notify Medicare that they have ORM are strongly encouraged to report accurate ICD-9 or ICD-10 codes as Medicare’s claims processing contractors will use this information to pay accordingly. In other words, reported ICD-10 codes will be key to challenging any conditional payment Medicare may be requesting reimbursement on and will be central to the determination of what items should or should not be included in a Medicare set aside.


The use of ICD-10 is effective October 1, 2015. ICD-10-CM is the new coding system for treatment in clinical settings. ICD-10-PCS is the new coding system for procedures in hospital settings. ICD-10 will go from about 18,000 existing codes (3,824 procedure codes and 14,025 diagnosis codes) to over 140,000 codes (71,924 procedure codes and 69,823 diagnosis codes). ICD-10 offers full description, greater detail and consistency within each code set; uses modern terminology for descriptions, based on modern technology; captures more specific data, therefore allows deeper analysis of data. ICD-10 structure will be able to accommodate thousands of new codes, now and into the future.

The industry expects workers’ compensation jurisdictions to adopt ICD-10 changes to billing (electronic and paper) rules/requirements. Most also expect WC jurisdictions to adopted changes to their EDI/reporting rules and requirements to align ICD-10 codes. It is also expected that states adopting drug formularies and nationally-recognized treatment guidelines will utilize ICD-10 diagnosis and procedure codes for compliance. Therefore, most expect ICD-10 codes will have a significant impact on all components of Medicare Secondary Payer compliance, including mandatory insurer reporting, conditional payments, and Medicare set asides.

For more than a year, Helios has been assisting clients with preparations for the adoption of ICD-10. In addition to testing systems and data, Helios created its own platform for converting ICD-9 codes to ICD-10 codes and vice versa. Our ICD look up tool allows clients to look up codes by matching specific terms. Our search tool also allows clients to use diagnosis codes or cause of injury codes to search for ICD-9 and ICD-10 codes and translate them into either one for use in mandatory insurer reporting, which of course also assists with conditional payments and set aside compliance. Should you be interested in speaking with us about this or any of our other Medicare Secondary Payer compliance products and services, please contact us at 888.672.7674, or at To sign up for our ICD-9/ICD-10 Search Tool, please visit

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