Quality & Practice

ICD-10 Codes - New Look, New Features

The International Classification of Diseases, 10th Edition Procedure Coding and Clinical Modification-ICD-10-CM will be implemented in offices, hospitals, and medical centers across the United States by 2015. Even though this "new" version was developed over 20 years ago and has been in use in other countries for well over a decade, the United States has been slow to embrace and implement it fully. Time and space have simply run out in the previous edition widely known as ICD-9.

ICD-9 is over 30 years old and no longer reflects advances in medical knowledge or technology. It does not have any more room to grow to adapt to these advances and has reached its capacity at 14,000 codes. ICD-10-CM on the other hand has ample room to grow to approximately 68,000 codes. This dramatic increase in codes is due to greater flexibility with the use of three to seven characters per code. The first code character is an alpha code and, therefore, codes have been tailored to be more specific in identifying a precise diagnosis. Each code can be divided into three parts to denote its specificity:

  • Characters 1-3: Category
  • Characters 4-6: Etiology, anatomic site, severity or other clinical detail
  • Character 7: Extension

ICD-10 codes have some additional features that enhance their specificity, including laterality, code extensions for injuries and external causes of injuries, and combination codes for diagnosis and symptoms. Taking all these characteristics into account, we can see how codes work by looking at the following examples:

  • S52: Fracture of forearm​
  • S52.5: Fracture of lower end of radius ​
  • S52.52​: Torus fracture lower end of radius​
  • S52.521​: Torus fracture of lower end of right radius​
  • S52.521A​: Torus fracture of lower end of right radius, initial encounter for closed fracture ​

Additional benefits of ICD-10 include better data for measuring quality, safety and efficacy of care, improvement in conducting research, epidemiological studies and clinical trials, improving clinical, financial and administrative performance, and preventing and detecting health care fraud and abuse.

The International Classification of Diseases Procedure Coding System 10th Edition (ICD-10- PCS) will also become effective on October 1, 2013. This portion of ICD-10 is unique to the United States and will replace ICD-9 volume 3. These sets of codes are only utilized for hospital inpatient coding and do not replace CPT in outpatient settings. These code sets have also experienced growth, going from approximately 4, 000 to 87,000. Just like their ICD-10-CM counterparts, the ICD-10-PCS codes are alphanumeric and seven characters long. They provide greater detail to describe complex medical procedures, and they describe exactly what has been done to the patient. ICD-10-PCS code structures are detailed in the following manner:

  • Character 1: Name of Section
  • Character 2: Body System
  • Character 3: Root Operation​
  • Character 4: Body Part
  • Character 5: Approach
  • Character 6: Device
  • Character 7: Qualifier  

For example, right knee joint replacement would be OSRCOJZ:

  • O = Medical Surgical Section
  • S = Lower Joints
  • R = Replacement
  • D = Knee Joint, Right
  • O = Open
  • J = Synthetic Substitute
  • Z = No qualifier

CMS has made it clear that there will not be a grace or transition period for implementation. ICD-9 codes will not be accepted for services rendered on or after October 1, 2013. Also, adherence to the official coding guidelines in all health care settings is required under the Health Insurance Portability and Accountability Act. Everyone who submits claims electronically currently does so by utilizing a set of transaction standards for electronic health care claims called Version 4010/4010A. The arrival and implementation of ICD-10 also brings with it a change in this area. Electronic claims submitted on or after January 1, 2012, must use the new and updated transaction standard called Version 5010. After January 1, 2012 electronic claims that do not use Version 5010 standards cannot be paid. To allow time for testing, CMS will accept electronic claims using either Version 4010/4010A or Version 5010 standards from January 1, 2011-December 31, 2011. These transitions will also more than likely occur at the same time for private payers as well.

Q&A: Automatic Hospitalist Consultations

The following Q&A addresses a common question in PM&R: the legality of the automatic hospitalist consultation.

Q: I am an inpatient rehab director of a small community rehab unit and am wondering about the legality of automatic hospitalist consultation. I am in a free-standing building with a 20-bed rehab unit and a 60-bed mental health unit where there is an internist contracted with the hospital to automatically provide consultation and medical management of all the patients in the building. Since I am the attending and primary physician, do I have to consult this physician? What is the legality of automatic contractual consultations even if I think a patient may not require it?

A: It is our suggestion that unless there is a medical necessity for a hospitalist consult, there is a risk of insurance fraud if ever audited. Consults should be based on medical necessity.

Remember, the attending physician decides whether any other physician consultant is necessary, including the contractual one from the hospital. As the attending physician, if you believe the patient tends to have multiple medical issues (end state renal disease on hemodialysis, tracheostomy, percutaneous endoscopic gastrostomy, sepsis, total parenteral nutrition, uncontrolled diabetes mellitus, etc.) that are best addressed by the medicine service and are well documented in the medical record, then that is your decision. Also, it goes without saying: If the consult is not necessary, don't request it. The internist consult cannot be justified if the patient is medically stable.

Every effort has been made to ensure the accuracy of PM&R In Practice. The content does not imply endorsement by nor official policy of AAPM&R. The official policies and specific resources of all governmental agencies and other professional organizations should be looked at by the reader. Helpful resources for more information include the CMS Web site, AMA CPT Book, and the ICD-9-CM code book. The information provided is not intended to be legal advice, but merely conveys general information related to legal issues commonly encountered. Nothing provided herein should be used as a substitute for the advice of competent legal counsel.