Big ICD-10 Challenges Ahead

The transition to ICD-10 codes has been official for the past year, but many challenges lie ahead.aug icd 10

When medical professionals made the switch to the 10th revision of the International Classification of Diseases, 10th revision (ICD-10) last October, the conversion was monumental.

Many industry stakeholders argued that the ICD-9 code set had become outdated, and the introduction of ICD-10 would offer health care providers more and better data, which would, in turn, lead to higher-quality patient outcomes.

Moving from ICD-9’s 14,025 numeric codes to ICD-10’s 69,823 alphanumeric codes, however, proved more of a jump than a gentle transition. And given that CMS is planning to add another 5,500 codes to the ICD-10 diagnostic library this year, it’s no wonder some have likened becoming fluent with ICD-10 to learning a whole new language.

“For coding professionals, going from using ICD-9 to ICD-10 code sets is like transitioning from speaking English to conversing only in French,” says Ezequiel Silva III, MD, FACR, chair of the ACR Commission on Economics. Silva believes there is a danger in shifting dialects so quickly. “When learning a new language, you start with the basic terminology,” says Silva. “But that’s tricky when it comes to medical coding. We have to make sure the codes we’re using aren’t too limited, even early on in the transition.”

As Silva implies, the expanding lexicon isn’t the only challenge facing those dealing with claims submissions. During the first year of ICD-10’s implementation, Medicare — along with some other large health insurers — has taken a lenient stance on claims denials, electing not to deny or audit claims if coders make liberal use of unspecified, simplistic codes. An example of the evolution from unspecified codes to codes with much more specificity is the diagnosis of unspecified osteopenia. As part of the transition to ICD-10, CMS removed one of the common codes used for unspecified osteopenia, M85.80 (“Other specified disorders of bone density and structure, unspecified site”), from the National Coverage Determination for Bone Mass Measurement. In its place, CMS added a list of ICD-10 diagnosis codes within the subcategory of M85.8-. CMS now requires physicians specify the site and laterality for the disorder of bone density and structure by adding an additional digit(s) and no longer accepts the unspecified code.

However, the grace period for avoiding the use of appropriately stringent codes comes to an end on Oct. 1 of 2016. And no one is quite sure how rigorous insurers will be about cracking down on the use of unspecified codes. Some observers worry this uncertainty will lead to a wave of claims denials.

But radiologists can take practical steps to minimize such denials. Most importantly, notes Margaret Fleming, MD, assistant professor of radiology and imaging sciences at Emory University in Atlanta, radiologists must brush up on the specific information they should include in each report; doing so will provide coders with the best chance at submitting accurate claims. Emory takes a targeted approach to educating radiologists about correct reporting. Instead of simply providing reference guides, says Fleming, “our executive committee appointed radiologist champions to go out and talk to the radiologists in person,” educating them on the most relevant information to include in their reports.

Fleming provides the example of Emory’s musculoskeletal division to illustrate how this worked in action. “We discussed fractures and how they should be described,” says Fleming. “For instance, right versus left, displaced versus non-displaced, which bone (including the number of the digit if in the hand or the foot), acute or chronic, delayed or routine healing, etc.” This level of specificity will help coders file claims that are as accurate and descriptive as possible, decreasing the odds claims will be denied.

Renée C. Engle, senior vice president of client services at MSN Healthcare Solutions, a medical billing services and practice management solutions company, agrees that simply providing reference materials is not sufficient to effect a successful transition. Using materials that cross-reference ICD-9 and ICD-10 codes, says Engle, “has been beneficial but not a complete solution. The physician champion model worked best for us and continues to prove to be the most effective method for enlisting radiologists’ support.”

Kim Snyder, CPC director of client services at MSN Healthcare Solutions, concurs that the personal touch is important. “Not only are physician champions key when it comes to monitoring progress, but they’re also instrumental in engaging the radiology group to update radiology templates,” she says. “The additional prompts in the dictation templates remind physicians that additional clinical considerations or information is needed.”

Apart from training, another area that bears constant scrutiny is the entity’s cash flow, which suffers as a result of claims denials. The decision to employ tactics such as putting off unnecessary purchases is a subjective decision. However, with the potential for claims denials to increase, Silva advises circumspection: “I do not think it’s a bad idea to go into the last quarter of 2016 with the assumption that there may be some cash flow shortages due to either processing or outright claims denials.”

Protecting the bottom line, although important, isn’t the only reason radiologists should take the new codes seriously. Besides the fact that more accurate claims reporting is the right thing to do to ensure quality patient care, Silva predicts that with the new era of value-based medicine upon us, the specificity inherent in ICD-10 codes will provide radiologists with a bonanza of data. And this data will be useful to mine when trying to qualify for upward reimbursement adjustments.

“Fast forward two to three years from now when the Merit-Based Incentive Payment System (MIPS) kicks in,” says Silva. “We’ll start to see episode groups, and we’ll see radiologists judged not just on procedure and diagnosis coding, but on larger episodes of care. When that happens, diagnosis codes are going to inform the evaluation process.” Silva hopes that practices are using the grace period not to relax, but to become well-versed with the new code set, thereby positioning themselves for future success.

By taking these lessons to heart, radiologists will put themselves in a good position to avoid an interruption in their finances. Maria Tran, economics analyst for the ACR, has some advice to keep radiologists and coders on the straight-and-narrow path: “To avoid most coding denials, the radiologist should clearly document the clinical history that is pertinent to the test and specify the laterality,” notes Tran. “And coders should code to the highest level of specificity, ensuring that each study is supported by a diagnosis or symptom that justifies the medical necessity.” Doing so will safeguard business operations and allow radiologists to continue doing what they do best: take care of patients.

Learn more about the transition to ICD-10 on the ACR ICD-10 resource page at

By Chris Hobson, Imaging 3.0 senior communications manager


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