Nix the X: Why You Should Approach ICD-10 Crosswalks with Extreme Caution

April 20th, 2015

Looking for an ICD-10 easy button? Well, join the club—because it seems like every way you turn, healthcare professionals are clamoring for an automatic, out-of-the-box solution to the ICD-9-to-ICD-10 translation problem. And plenty of entities have stepped up to satisfy that demand. The problem is, most of their offerings—including automated software systems and plug-and-chug conversion tools like general equivalence mappings (GEMs)—produce less-than-satisfactory results. In fact, relying on those solutions alone could leave you not just unsatisfied, but completely blindsided by the transition to ICD-10. And with ICD-Day—October 1, 2015, that is—rapidly approaching, you can’t afford to waste another second searching for a silver bullet that doesn’t exist.

“But, wait!” you protest. “It does exist! I have seen it with my own eyes!” Well, if you’re referring to the solutions I mentioned above—and I’m assuming you are—then I’m sorry to be the one to disillusion you, but that’s exactly what they are: illusions. And here’s why you shouldn’t be fooled into believing they’ll be your sole saving grace:

1. GEMs cannot reliably produce one-to-one code translations.

As this EHR Intelligence article explains, GEMs were never intended to serve as single-code translation dictionaries. Because of the way they’re structured—in clusters of two to four related codes—GEMs may map one ICD-9 code to several ICD-10 codes and vice-versa. In other words, the majority of the time, GEMs won’t generate a single ICD-10 match for a single ICD-9 code, because “they are an incomplete method of translation,” EHR Intelligence reports. This ICDLogic whitepaper echoes that sentiment: “…the two systems differ so widely that all attempts at translation offer only a series of compromises and subjective choices. This is necessarily so because there is no ‘mirror image’ of one code set in the other.”

So, why do GEMs exist in the first place? EHR Intelligence has an answer for that, too: “GEMs can be used by anyone with a need to convert large batches of data, which will include payers, providers, researchers and informatics professionals, coders, vendors, and anyone with historical ICD-9 data that needs to be usable in the future.” Tasks that are well-suited to the use of GEMs include:

  • Generating converted data sets for large databases of ICD-9 codes.
  • Aligning data sets for long-term clinical studies that span the transition to ICD-10.
  • Analyzing data collected before and after the transition.
  • Creating reimbursement mappings to ensure claims containing ICD-10 codes will be paid following the transition.

2. There are no regulations or industry standards governing the creation and use of GEMs.

Although most people associate GEMs with CMS—and thus, assume they’ve been through some type of government quality control review process—the truth is that there are “numerous variations of the ‘national’ GEMs available from a variety of both public and private sources,” ICDLogic explains.

Furthermore, despite numerous efforts—dating all the way back to 2007—to establish national mapping standards for all GEMs, “No industry-wide standards that we are aware of were achieved and today there are many GEMs available from a variety of sources, EHR vendors and payers,” ICDLogic states. “No one really knows whether they are consistent or what the individual organizing principles and assumptions are that each developer used.” Essentially, putting all of your eggs in the GEMs basket would be like eating at a restaurant that doesn’t have to follow any health and safety codes—and that’s a gamble you definitely don’t want to take.

3. There is no automated tool or software that can generate accurate ICD-9-to-ICD-10 conversions 100% of the time.

I get it; it’s 2015, and there’s an automated alternative for pretty much every task. Heck, Google has even created a self-driving car. But when it comes to translating ICD-9 codes into the language of ICD-10, there’s no technology sophisticated enough to do the thinking for you. In fact, as ICDLogic points out, the new code set wouldn’t function the way it’s supposed to without the human decision-making factor: “GEMs are not finite crosswalks because they contain numerous instances of mappings where human intervention and judgment—based on analysis of the clinical documentation—is required to complete many of the links.”

And because most software vendors used GEMs to develop their ICD-10 conversion tools, the same cautionary advice applies to their use as well. Bottom line: while GEMs and code conversion programs can streamline the code selection process by narrowing down your options, you’ll still need to enlist your clinical expertise and critical thinking power to get all the way to the finish line. Here are the code translation steps we recommend following to determine an accurate match:

  1. Run your ICD-9 code through a conversion tool—like this one—and use the ICD-10 output as your starting point.
  2. Look up that ICD-10 code in the Tabular List.
  3. See if there are any variations of the code that offer a higher level of specificity.
  4. Check the associated category and chapter headings for additional coding instructions.
  5. If you can, code for the patient’s actual condition (e.g., patellar tendinitis) rather than merely the result of that condition (e.g., knee pain).
  6. If applicable, list the relevant external cause codes. You can find these codes—which further describe the circumstances of the injury or condition—in chapter 20 of the Tabular List.

All that being said, if you want to use a software to help you streamline your ICD-10 coding process, look for one that uses detailed, defensible electronic documentation as the foundation for code selection—and then empowers you to make the final call on the best code for the job. In other words, your software should get you halfway across the street, but it’s up to you to get all the way to the other side.

End-to-End Testing Volunteer Applications Due January 21

December 30th, 2014
ICD-10, Preparation, Testing Week

Despite recent buzz about yet another ICD-10 delay, as of now, the implementation of the new diagnosis code set will go forward as planned on October 1, 2015. To prepare for the transition, Medicare will conduct a second round of end-to-end testing with a new sample group of providers this April. As with the previous end-to-end testing exercise, this effort will verify that:

  • Providers and other claim handlers are able to submit Medicare claims containing ICD-10 codes
  • Medicare’s software can correctly process claims containing ICD-10 codes
  • Claim submission results in accurate remittance advices

CMS will select approximately 850 test participants from its pool of volunteers. This sample will represent a wide variety of geographic locations, provider types, and claim submission processes. Want to get in on the action? Here’s how to throw your hat in the volunteer ring:

  1. Visit your local MAC website to get a volunteer form.
  2. Complete the form and turn it in by January 21.
  3. Keep your eyes peeled for a selection notification from CMS.
  4. Receive further testing setup instructions from CMS by January 30 (if you’re selected).

Please note that all volunteers must be able to submit future-dated claims as well as provide valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and beneficiary Health Insurance Claim Numbers (HICNs). If you are selected for testing and are unable to provide this information to your MAC by February 20, 2015, CMS will eliminate you from the test group.

CMS has an additional end-to-end testing period planned for July 20–24, just a hair over two months before the go-live date. As a side note, those who volunteer to participate in the April testing exercise don’t need to reapply for the July test.

CMS will use the data it collects during the testing week to address any lingering ICD-10 issues and develop appropriate educational materials, thus ensuring a smooth transition come October 1.

For more information, check out the MLN Matters fact sheets found here and here.

Is Another ICD-10 Delay on the Legislative Menu?

December 23rd, 2014

Just as too many cooks in the kitchen can spoil the soup, too many lobbyists on Capitol Hill can turn a piece of legislation into a convoluted casserole of random additions and amendments. But despite the recent efforts of a small-but-powerful group of physician advocates, a proposed two-year ICD-10 delay did not get baked into the $157 billion Departments of Labor-Health and Human Services-Education spending bill that Congress passed on December 11.

This was a huge win for the pro-ICD-10 camp, which includes the American Health Information Management Association (AHIMA), national and regional hospital associations, physician groups, and numerous healthcare companies and organizations. Still, there is a lingering concern among these stakeholders that the October 1, 2015, ICD-10 implementation date is no sure thing. After all, the previous go-live date of October 1, 2014, didn’t get the kibosh until this past March, when lawmakers slipped language ordering a one-year delay into HR 4302—more commonly known as the Sustainable Growth Rate (SGR) fix bill.

So, assuming that Congress whips up another batch of SGR legislation this coming spring—as it has done for 17 consecutive years—the question at hand is: will history repeat itself? Will Congress mix an ICD-10 delay into the annual fix bill yet again? Only time will tell—and a lot could happen between now and March 31, especially with a new crop of congresspeople descending upon Washington in January.

But even if those opposed to the ICD-10 transition attempt to pull the same maneuver in 2015, experts say their efforts likely will be in vain. As Chuck Buck, the publisher of ICD10monitor, writes in this blog post, “…it will be hard to convince members of Congress that more time is needed. If Congress didn’t see the need to enact a delay in December, why would they be convinced to delay months later in March?”

Perhaps one of the biggest motivators for Congress to make sure the transition happens in 2015: the financial implications of another delay. Many healthcare organizations have already invested millions of dollars into providing ICD-10 training for their staff and upgrading their technology and business operations to accommodate the new code set. And with a two-year delay, those organizations likely would have to redo much of that costly prep work. “The U.S. Department of Health and Human Services (HHS) estimates that the cost to delay the implementation could potentially reach $6.8 billion,” Buck continues in his post. Plus, the cost of another delay isn’t limited to that astronomical price tag; putting the ICD-10 implementation on the backburner for two more years would introduce yet another barrier to providing the best, most cost-effective patient care possible.

At this point, it’s too early to say for sure that the ICD-10 switch will happen in October. However, one thing is certain: another delay would be tough to swallow, and it would leave a lot of people in the healthcare industry with a bad taste in their mouths.

ICD-10 is on Hold, but Your Preparations Shouldn’t Be

August 26th, 2014
ICD-10, Transition

When news of the ICD-10 implementation delay broke this past spring, the reaction among healthcare providers was similar to what you might expect from a class of college students receiving news of a term paper extension: a collective sigh of relief interspersed with a few high-fives and cheers.

If you’re among the crowd of healthcare professionals who are thanking their lucky stars for the one-year pushback, keep in mind that the new deadline won’t make the transition any less challenging or resource-intensive—it merely delays the inevitable. And just like the first time around, procrastination won’t get you anywhere. Because at some point—just as those college students are going to have to buckle down and crank out their essays—you’re going to have to start submitting claims with ICD-10 diagnosis codes. And once the go-live date of October 1, 2015, is upon us, you’ll have a pass-fail situation on your hands as carriers will deny all claims lacking ICD-10 codes.

So, what should you be doing in the meantime? That question is currently on the minds of many medical professionals. According to this Government HealthIT article—which summarizes a study by the American Health Information Management Association and eHealth Initiative—the preparatory items of highest concern within the healthcare community are documentation improvements, workforce training, and partner testing.

The first two tasks are closely related; after all, to improve the quality and efficiency of your practice’s documentation processes, you’ve got to not only educate your staff about what is expected of them, but also allow them the opportunity to practice creating documentation that meets your standards. The data speak to that relationship with 61% of survey participants saying they’re training more staff in preparation for the switch and 68% conducting additional training and practice exercises to help combat the expected productivity loss. Furthermore, about one-third of respondents said they plan to hire more coders.

When it comes to testing, the results are a little more split. About 40% of participants in the above-cited study plan to begin end-to-end testing by the end of 2014 with an additional 25% saying they’ll start in 2015. On the other hand, 41% indicated that they don’t know how to test, and 45% admitted they’re unsure of how ready their business partners are. (If you’re not up to speed on the ins and outs of ICD-10 testing, check out this blog post on external testing and this one on internal testing.)

Of special concern to physical therapists is coordination with top referral sources. As certified coder and medical coding auditor David Zetter says in this HealthLeaders Media article, “The person in your office who is taking that phone call or referral needs to understand what information they need from that referral partner to make sure that diagnosis code is as accurate as possible and includes all the information.”

Another thing to consider? How your practice—or, more specifically, your EMR—will handle dual coding. Medicare allows providers to submit claims up to a year after the actual date of service, which creates a bit of a pickle. As the HealthLeaders Media article explains, “…a claim submitted for service before October 1, 2015, will require an ICD-9 code even though you may submit it in January 2016—but that claim will require the new ICD-10 code as well.”

October 1, 2015, might seem like a long way off, but with so many things to check off of your to-do list before ICD-Day, you’re certainly better off being proactive. That way, by the time the transition rolls around, you won’t be holding your breath and hoping for an extension.

Was your practice ready for the original ICD-10 transition date? How have your preparatory plans changed in the wake of the delay? Share your thoughts in the comment section below.

CMS Sets ICD-10 Transition Date, Releases Testing Information

August 5th, 2014
ICD-10, Testing Week, Transition

It’s official: October 1, 2015, is the new ICD-10 transition deadline. While that gives providers ample time to prepare for the switch, it’s imperative that those affected by the change stay on top of their prep work to ensure a timely and seamless transition when that day finally arrives.

To that end, CMS recently revealed its testing plan for the months leading up to the ICD-10 implementation date. According to this MLN Matters article, CMS is taking “a comprehensive four-pronged approach to preparedness and testing” in an effort to ensure everyone in the healthcare community has enough practice with submitting the new codes before it becomes a requirement. The four pieces of the testing plan are:

  • Internal testing of CMS’s claims processing systems
  • Release of downloadable beta testing tools
  • Acknowledgement testing
  • End-to-end testing

As you may recall, CMS successfully conducted acknowledgement testing this past March. To build on that round of testing, CMS has invited all providers, suppliers, billing companies, and clearinghouses to submit acknowledgement test claims any time before October 1, 2015. Additionally, CMS has scheduled special acknowledgement testing weeks in November 2014 and March and June 2015. During these testing periods, participants will have access to real-time desk support. You do not need to sign up to participate in these testing activities. If you’re interested, simply contact your Medicare Administrative Contractor (MAC) for more information.

CMS also plans to facilitate end-to-end testing in January, April, and July of 2015. Approximately 2,550 volunteers representing a variety of regions and provider types will be selected to participate in these testing events, which involve submission of test claims with ICD-10 codes to Medicare as well as the provider’s receipt of a Remittance Advice (RA) that explains the adjudication of the claims. According to the above-cited MLN Matters article, CMS will soon release information on the volunteer registration process.

For more information on these testing initiatives, as well as links to various testing resources and tools, please refer to the MLN Matters article.

How to Conduct External Testing for ICD-10

May 28th, 2014
ICD-10, Preparation, Transition

In a previous blog post, we explained how and why you should test the ICD-10 code set inside your practice. Now, let’s talk about external testing—that is, verifying that all of your outgoing and incoming data transmission processes are completely ICD-10 ready. That way, by the time the transition date—which is set for October 1, 2015, according to recent hints from CMS—rolls around, there will be no question of whether you’ll get paid.

In this article, ICD10Watch editor Carl Natale explains the importance of proper external testing. In his words, such testing should allow you to:

  1. “Verify that [your] practice can submit, receive, and process data containing ICD-10 codes.
  2. “Understand the impact that clearinghouse and payer policies will have on the transactions.
  3. “Identify and address specific problems.”

If you find the task of architecting—and executing—a comprehensive external testing plan to be more than a little overwhelming, relax. As Jennifer Bresnick writes in this EHR Intelligence article, you should employ a “multi-phase approach to testing to cover different testing objectives in a reasonable time frame…” Essentially, treat ICD-10 testing as you would a fine dining experience; you wouldn’t scarf down your appetizer, entrée, and dessert all at once, and you don’t want to dive into all portions of your testing at once.

Instead, break it down into stages, and be sure to set specific, measurable, attainable, relevant, and timely (SMART) testing goals. Then, present your goals and target deadlines to your staff as well as your business partners and vendors. As you’re formulating your plan, be sure to research where your partners are in their own ICD-10 preparations. That way, you’ll know where you might need to build a little bit of cushion into your schedule so you don’t get derailed by surprise setbacks.

Natale pulled the following key action items from the external testing plan CMS provides here:

  • Pinpoint and prioritize the parties with whom you need to test
  • Make arrangements to submit test claims to your clearinghouse, billing service, and/or payers
  • Analyze the results of your test submissions
  • Adjust your clinic’s processes accordingly

Furthermore, according to this article, CMS and the Workgroup for Electronic Data Interchange (WEDI) recommend that you perform testing with claims representing all of the code categories your practice uses, especially those that may be susceptible to “common errors, such as mistaking a zero for [the letter] O” so that you will see what happens if your claims don’t go through. And regarding test claims that contain real patient data—a.k.a. protected health information—take heed of these cautionary words from the American Medical Association (AMA): “Be sure to follow all appropriate security and privacy measures to protect the data, such as sending the transactions using a secure connection.”

If your practice only works with a certain clearinghouse or billing service, you’ll have a simplified external testing experience because you really only need to ensure they can receive the codes. However, you should also confirm that such parties are conducting their own testing initiatives with payers and other clearinghouses. Otherwise, it could affect your cash flow.

While many experts recommend that you dedicate six to nine months to your external testing endeavors, we say the more testing you can do, the better. So as we count down the weeks and months to transition time, keep a pulse on your partners’ testing preparations so you can get started as soon as you’re ready.

Does your clinic have a plan for external ICD-10 testing? What testing questions do you have? Share your thoughts in the comment section.

Is It Ever Okay to Use an Unspecified ICD-10 Code?

May 15th, 2014

One of the main selling points of the ICD-10 code set is the incredible degree of specificity it provides. As such, the protocol for selecting the correct ICD-10 code is to choose the one that represents the patient’s condition in the most detailed way possible. And that means that, in general, submitting “unspecified” diagnosis codes—something you might have grown accustomed to with ICD-9—is a big no-no. In fact, doing so could lead to claim denials. But as the saying goes, there’s an exception to every rule—and in this case, that exception stems from differing definitions of the word “unspecified.” As Joseph C. Nichols of Health Data Consulting (HDC) states in this report, “While it is true that we should be as specific as possible to assure the best quality information, most of the discussions around unspecified codes don’t really get at what ‘unspecified’ means relevant to codes let alone when they should or shouldn’t be used.”

The True Meaning of Unspecified

This presentation by the National Association of Rural Health Clinics (NARHC) defines unspecified coding as “Coding that does not fully define important parameters of the patient condition that could otherwise be defined given information available to the observer (clinician) and the coder.”

In this context, the concept of “unspecified coding” seems totally independent of the use of “unspecified codes.” It merely refers to coding that does not account for details that are, in fact, available to the coder.

“Unspecified codes,” on the other hand, are actual ICD-10 codes that represent actual patient conditions and diagnoses—albeit not to the standard of specificity ICD-10 is meant to deliver. For example, unspecified codes do not indicate the anatomical laterality—such as right, left, or bilateral—of injuries and other conditions. Most unspecified codes simply state the diagnosis and contain the word “unspecified” within their descriptions (e.g., S13.101, Dislocation of unspecified cervical vertebrae). But when does the use of these codes fall under the umbrella of “unspecified coding” as discussed above? And how do you know when it’s acceptable to use an unspecified code?

When Can You Use Unspecified Codes?

The NARHC and HDC have identified the following examples of situations in which it may be acceptable to use an unspecified code:

  • The clinician does not yet know enough about the patient’s condition to select a more specific code (because the patient is still in the early stages of evaluation, for example)
  • The provider is not directly related to, or involved with, the diagnosis the code represents
  • The clinician does not have enough expertise in the area of the diagnosis to describe the condition to the degree of specificity a specialist would be able to provide

To see specific examples of the scenarios above, refer to page eight of this document. If you’re curious as to why the coders or clinicians in these instances wouldn’t simply choose a more specific code—even if they didn’t necessarily know all the facts about the case—here’s a word of caution from HDC’s Nichols: “Forcing coders to use a ‘specified’ code may result in the unintended consequence of creating misinformation that assumes something is true when there is no real evidence to support that level of specificity.” And recording inaccurate diagnoses for patients could compromise not only the quality of their treatment, but also the historical accuracy of their medical records. For that reason, it’s better to use an unspecified code of which you are confident than a specific code of which you are unsure.

When Should You Steer Clear of Unspecified Codes?

Per the NARHC and HDC, coders and practitioners should not use unspecified codes when:

  • They have enough information to define the condition in a more detailed way
  • They lack knowledge regarding basic concepts such as:
    • Laterality (e.g., right, left, bilateral, or unilateral)
    • Anatomical location
    • Trimester (of pregnancy)
    • Type of diabetes
    • Established complications or comorbidities
    • Information about severity, acuity, or other parameters
  • They are providing care that necessitates a more specific diagnosis
  • They are specialists, and thus should be able to provide more detailed information about a particular condition

Check out page nine of this document to see specific examples of the scenarios above.

Remember: coding, like documentation, is all about justification. Just as you should be able to justify the way you document, you should be able to justify the way you code. So, if you use an unspecified code simply because you don’t want to take the time to locate a more specific one—even though you have the tools necessary to do so—you’re definitely putting yourself at risk for some pretty terrible consequences (I’m talking claim denials). If you don’t feel like the codes you’ve provided give a complete picture of a patient’s condition, chances are that your payers will feel the same way. Essentially, listen to your gut and use common sense—that way, you’ll always be able to justify your coding decisions.

6 Common ICD-10 Myths Busted

April 15th, 2014

The impending transition to ICD-10 has caused quite a stir among medical professionals, politicians, and news personalities alike. With so many people talking at once, it’s tough to know who’s speaking the truth and who’s stretching it. Not to worry, though. Here, I’ll bust all the common ICD-10 myths clouding the airwaves and set the record straight once and for all.

Myth #1: There absolutely will not be another ICD-10 implementation delay.

Truth: Not so very long ago, we would have placed this “myth” in the truth category, because everyone—from CMS to HHS—was saying the transition would definitely happen October 1, 2014, regardless of whether medical providers and insurance carriers were prepared. And then came HR 4302. Originally drafted as the 2014 Sustainable Growth Rate “fix” bill, this piece of legislation somehow came to include a provision to delay the mandatory ICD-10 implementation deadline at least a year. (According to Sharon Canner, senior director of public policy of the Ann Arbor, Michigan-based College of Healthcare Information Management Executives (CHIME), the fact that this is an election year probably has a lot to do with the last-minute ICD-10 delay making it into this bill.) So now, the earliest the US will make the switch is October 1, 2015.

Myth #2: To code correctly in ICD-10, coders will end up wasting hours upon hours sifting through thousands of ultra-specific cause codes.

Truth: Sure, the Internet is full of humorous nods to Chapter 20 of the ICD-10-CM Manual (External Causes of Morbidity), but while many external cause codes are good for a hearty chuckle or two—case in point: Struck by Orca—the truth of the matter is that in most circumstances, these codes are optional as there is no national requirement mandating their use. As explained in this Just Coding article, “…unless coders are already reporting external causes in ICD-9-CM (E000-E999), they are unlikely to have to start using them…This is because the use of external cause codes is voluntary unless required by a payer or state reporting mandate.”

Myth #3: ICD-10 is part of Obamacare.

Truth: As I mentioned above, ICD-10 was originally slated to go into effect on October 1, 2014. Calendar wise, that put ICD-10 in close proximity with the Affordable Care Act, which led many people to wrongly assume that the two were linked. Even national news outlets—perhaps most notably, Fox News—took media spin to a whole new level by erroneously referring to ICD-10 codes as “Obamacare codes.” I guess the fact-checker must have called in sick that day.

Myth #4: Once the switch to ICD-10 happens, ICD-9 will be gone for good.

Truth: While all HIPAA-covered entities—including most practitioners and payers—must change over to ICD-10, the ICD-10 mandate does not apply to non-covered entities such as workers’ compensation, disability, and auto insurers. Therefore, as Carl Natale writes in this ICD-10 Watch article, “If the non-covered entities don’t want to switch to ICD-10 coding, they don’t have to and can require healthcare providers to submit medical claims with ICD-9 codes.” But, as this EHR Intelligence article argues, it’s probably in everyone’s best interest to make the switch eventually because “the increased detail and specificity will be just as useful for worker’s comp as it is for the emergency department.” The article also mentions that CMS plans to work with non-covered entities and Medicaid programs to help them adopt ICD-10 codes and thus, avoid falling behind the rest of the healthcare world.

Myth #5: There’s a direct ICD-10 crosswalk for each ICD-9 code.

Truth: Everybody wants an ICD-10 easy button, and plenty of so-called ICD-9 to ICD-10 conversion tools have popped up to fill that demand. But while such tools can give you a good idea of where to start, they are by no means foolproof. Why? Because ICD-9 codes lack the specificity that ICD-10 codes offer. So for each ICD-9 code, there could be dozens—sometimes even hundreds—of possible ICD-10 equivalents. As such, automatic converters often will default to codes that do not represent the greatest possible level of specificity. And if you submit unspecified codes, you put your claims at risk for denial. According to Government Health IT, “University of Illinois Chicago researchers studied what happened when they applied a web-based ICD-10 converter to a bunch of ICD-9 codes. They lost information and potential reimbursements.”

So with conversion tools and General Equivalence Mappings (GEMs) off the table as standalone solutions, accurately translating ICD-9 codes into ICD-10 ones might seem like a tall order. Luckily, I’ve boiled the whole process down into five easy steps in this blog post.

Myth #6: ICD-10 codes will replace Current Procedural Terminology (CPT) codes.

Truth: It is true that ICD-10 includes a procedural code set (ICD-10-PCS). However, per CMS, this code set “will only be used for facility reporting of hospital inpatient procedures and will not affect the use of CPT.”

What other juicy ICD-10 gossip have you heard? Tell us in the comment section and we’ll let you know what’s fact and what’s fiction.

How to Convert ICD-9 Codes into ICD-10 Codes

March 25th, 2014
ICD-10, ICD-9

If you’ve ever visited a foreign country, you know how frustrating the language barrier can be. By learning a few key phrases before embarking on your travels, though, you can usually get by without too much trouble. The same goes for ICD-10. Yes, the new codes are complex, and yes, it’s going to take some time to become fluent in the language of ICD-10. But if you go into the transition with a handful of commonly used codes in your back pocket, you’ll feel much less overwhelmed by the switch.

Unfortunately, finding ICD-10 equivalents to ICD-9 codes is a bit more complicated than looking up “please” and “thank you” in your pocket English-to-German dictionary. Because ICD-10 offers a much higher degree of specificity than ICD-9, there are many cases in which a single ICD-9 code has several possible ICD-10 translations. To continue with the language metaphor, choosing the correct ICD-10 equivalent of a certain ICD-9 code is kind of like choosing the correct Eskimo term for the English word “snow.” There are dozens of options, and each one indicates a very specific type of frozen precipitation.

So, with cut-and-dried crosswalking off the table, how should you go about pinpointing the correct ICD-10 version of a particular ICD-9 code? Well, you should start by downloading the complete Tabular List of ICD-10 codes. You’ll find the most up-to-date version here. (Click the link labeled “ICD-10-CM PDF Format” under the section with the heading “2014 release of ICD-10-CM.”) When you open the PDF, you’ll see that the codes are organized by chapter. As a rehab therapist, you’ll deal mostly with chapters 13 and 19—“Diseases of the musculoskeletal system and connective tissue” and “Injury, poisoning and certain other consequences of external causes,” respectively.

If your PDF viewer has a search function, you might be able to find the code you’re looking for—or at least identify a few starting points—simply by entering the appropriate term in the search field. (You can also keyword search at Alternatively, you can begin your translation process using this ICD-9 to ICD-10 conversion tool. Remember—and I cannot stress this enough—you absolutely should not use this tool as a “plug-and-chug” crosswalk solution. Most of the time, the ICD-10 codes the tool suggests are not specific enough to use. In fact, you will see the following disclaimer message underneath the search field: “Keep in mind that while many codes in ICD-9-CM map directly to codes in ICD-10, in some cases, a clinical analysis may be required to determine which code or codes should be selected for your mapping.”

However, this tool does give you a good idea of where to start. For example, 719.46 (Pain in joint, lower leg) is one of the most commonly used ICD-9 codes among physical therapists. If you enter this code into the ICD-10 conversion tool I referenced above, it will generate a single result: M25.569 (Pain in unspecified knee). At first glance, it would appear that this code is the definitive equivalent of 719.46—after all, it’s the only ICD-10 code that appeared in the search results. The problem is, this code—though technically correct—is not the most correct code because it is not the most specific code available.

The whole point of ICD-10 is improved data due to increased specificity. If you do not use the most specific code possible, you risk having your claims rejected. Thus, you should avoid using an “unspecified” code if a more specific option exists. And in this case, there is almost certainly a more specific code available.

To find it, open the Tabular List and head to chapter 13 (the “M” code chapter). Scroll down to M25.56, the “Pain in knee” category. There, you’ll see code options for both the left and right knees. Chances are that you, as the therapist, know which knee is causing pain for the patient. Therefore, you should select a code that accounts for laterality: M25.561 (Pain in right knee) or M25.562 (Pain in left knee).

Furthermore, keep in mind that if it is possible to code for the specific condition that is causing the pain, you should absolutely do so. In this case, for example, if you determine that the patient is suffering from patellar tendinitis, you would select either M76.51 (Patellar tendinitis, right knee) or M76.52 (Patellar tendinitis, left knee) as the diagnosis code for this patient.

Finally, make sure you read the instructions at the beginning of each chapter and category. In some cases, you may need to submit an external cause code or attach a seventh character. At the beginning of chapter 13, for example, you’ll see the following directive: “Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.” Basically, if you know additional details about the cause of the patient’s condition, you should account for them using supplemental external cause codes from chapter 20. To continue with the knee pain scenario, if the patient developed patellar tendinitis as a result of running on a treadmill, you would indicate this scenario using the code Y93.A1 (Activity, treadmill).

So, to recap, when searching for the ICD-10 equivalent of a particular ICD-9 code, follow these steps:

  1. Use a simple conversion tool (like this one) to find a starting point.
  2. Consult the Tabular List (which you can download here) to determine whether a greater level of coding specificity is possible.
  3. If possible, code for the actual condition (e.g., patellar tendinitis) rather than the result (e.g., pain in knee).
  4. Within the Tabular List, check chapter/category headings for additional instructions regarding external cause codes or seventh characters.
  5. If applicable, identify pertinent external cause codes within chapter 20 of the Tabular List.

Have you started creating a list of ICD-10 equivalents to your most frequently used ICD-9 codes? If so, what advice or questions do you have? Share your thoughts in the comment section below.

Why Coding for Medical Necessity is So Crucial with ICD-10

March 18th, 2014

The switch to ICD-10 is coming on October 1, 2015, and to transition successfully, healthcare providers will need to change not only the actual codes they are using, but also the way they think about coding. Because with ICD-10, it’s not just about coding patient diagnoses correctly; it’s about coding the correct patient diagnoses.

This point is especially relevant to physical therapy providers. As this article explains, “Medical necessity can be a big problem in the physical therapy department.” Why? Well, in many cases, the condition a physical therapist treats is not technically the same condition that the referring physician treated. Sure, the patient may be seeking therapy for a condition that resulted from the original injury or condition—a common scenario for therapy referrals—but with ICD-10, it is absolutely crucial that the diagnosis coding accurately reflects that distinction.

To cut to the chase, that means a physical therapist cannot simply copy whatever ICD-10 code a physician sends over with a referral patient, because there’s a good chance that diagnosis code doesn’t validate the medical necessity of therapy treatment—and that means payers could deny reimbursement for the therapist’s services. The above-cited article offers the following example: “A patient suffers a stroke and is attending physical therapy. A lot of patients suffer strokes and don’t need physical therapy. The therapy is actually treating the residual effects of the stroke, so that’s what should be reported as the diagnosis on the claim form.”

Furthermore, the article addresses the now-common practice of using diagnosis code “cheat sheets” to ensure payment. As you probably know, certain CPT codes are only payable when used in conjunction with certain ICD-9 codes. For that reason, many providers stick to the codes they know will work—and often, those codes fall into the “generalized” or “unspecified” categories. But one of the main battle cries of the new code set is increased specificity, and the transition to ICD-10 represents a giant step away from the use of unspecified codes (unless one of those codes truly represents the most accurate description of a patient’s condition). Thus, if you submit an unspecified code when a more specific code is, in fact, available, you could put yourself at risk for claim denial.

And in the event that you do receive a denial, make sure you investigate the reason. The article I referenced earlier urges providers to research the following question: “Are the denials due to a lack of medical necessity or a lack of documentation?” The author also recommends that each practice designate one person to be responsible for following up on such denials.

Does your practice have a game plan for any claim denials you receive due to ICD-10? What advice or questions do you have?