ICD-10Sarah Enright

Provider Relations

What is ICD?• The ICD is the international standard diagnostic

classification for many health management purposes and clinical use including:– Analysis of the general health situation of population

groups– Monitoring of the incidence and prevalence of diseases

and other health problems in relation to other variables • Used to classify diseases and other health problems

recorded on many types of health and vital records.• Enables the storage and retrieval of diagnostic information

for clinical, epidemiological, and quality purposes.• Provides the basis for the compilation of national mortality

and morbidity statistics.

Who Maintains ICD-10?

• ICD-10-CM– National Center for Health Statistics (NCHS)– Centers for Disease Control and Prevention

(CDC)• ICD-10-PCS

– Centers for Medicare and Medicaid Services (CMS)

Federal Mandate

In January 2009, the Department of Health and Human Services issued a final rule requiring all HIPAA-covered entities to use ICD-10 diagnosis and procedure codes for HIPAA transactions with dates of service or dates of discharge on or after October 1, 2013.

HIPAA 5010 Compliance

Nomenclature Change

Why Transition to ICD-10?

• ICD-9 produces limited data about patients’ medical conditions and inpatient hospital procedures.

• ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice.

• The structure of ICD-9 limits the number of new codes that can be created; many ICD-9 categories are full.

Comparison ICD‐9‐CM ICD‐10‐CM

# of Characters 3‐5 Numeric

(+V and E codes)

3‐7 Alphanumeric

# of Codes ~ 13,500 ~ 68,000

Comparison ICD‐9‐CM ICD‐10‐PCS

# of Characters 3‐4 Numeric 7 Alphanumeric

# of Codes ~ 4,000 ~ 72,000

Diagnosis Codes

Procedure Codes

Structural Differences Between ICD-9 and ICD-10

Information Patterns

In general, ICD‐10 codes are more specific than ICD‐9.Certain cases exist where ICD‐9 is more specific than ICD‐10:

Method of detection eliminated in ICD‐10.Legal status and completeness of procedure eliminated in ICD‐10.

896.2   Traumatic amputation of foot  S98.011A  Complete traumatic amputation of (complete or partial) bilateral  right foot at ankle level, initial encounterwithout mention of complication S98.012A  Complete traumatic amputation of 

left foot at ankle level, initial encounterS98.021A  Partial traumatic amputation of right foot 

at ankle level, initial encounterS98.022A  Partial traumatic amputation of left foot

at ankle level, initial encounter

ICD‐9 Code and Description ICD‐10 Codes and Description

Differences in Specificity

Diagnosis Codes for Sprained and Strained Ankles: ICD-9-CM vs. ICD-10-CM

4 ICD‐9 Codes

845.00 Sprain and strain 

of ankle, unspecified 

site

845.01 Sprain and strain 

of ankle, Deltoid 

ligament/Internal 

collateral ligament

845.02 Sprain and strain 

of ankle, 

Calcaneofibular 

(ligament)

845.03 Sprain and strain 

of ankle, Tibiofibular 

(ligament) distal

72 ICD‐10 CodesS93.401A Sprain of unspecified ligament of right ankle ‐ initial 

encounterS93.401D Sprain of unspecified 

ligament of right ankle – subsequent encounter

S93.401S Sprain of unspecified ligament of right ankle – sequelaS93.402A Sprain of unspecified ligament of left ankle ‐ initial 

encounterS93.402D Sprain of unspecified 

ligament of left ankle – subsequent encounter

S93.402S Sprain of unspecified ligament of left ankle – sequelaS93.409A Sprain of unspecified 

ligament of unspecified ankle ‐ initial encounter

S93.409D Sprain of unspecified ligament of unspecified ankle–

subsequent encounterS93.409S Sprain of unspecified ligament of unspecified ankle–

sequelaS93.421a Sprain of deltoid ligament of right ankle  ‐ initial encounter

S93.421d Sprain of deltoid ligament of right ankle – subsequent 

encounterS93.421q Sprain of deltoid ligament 

of right ankle –Sequela S93.422a Sprain of deltoid ligament of left ankle  ‐ initial encounter

S93.422d Sprain of deltoid ligament of left ankle – subsequent encounterS93.422q Sprain of deltoid ligament 

of left ankle – sequelaS93.429a Sprain of deltoid ligament 

of ankle unspecified ‐ initial encounter

S93.429d Sprain of deltoid ligament of unspecified ankle– subsequent 

encounterS93.429q Sprain of deltoid ligament 

of unspecified ankle– sequela S93.411A Sprain of calcaneofibular ligament of right ankle  ‐ initial 

encounterS93.411D Sprain of calcaneofibular ligament of right ankle – subsequent 

encounter

S93.411S Sprain of calcaneofibular ligament of right ankle – sequelaS93.412A Sprain of calcaneofibular 

ligament of left ankle  ‐ initial encounter

S93.412D Sprain of calcaneofibular ligament of left ankle – subsequent 

encounterS93.412S Sprain of calcaneofibular ligament of left ankle – sequela

S93.419A Sprain of calcaneofibular ligament of unspecified ankle ‐ initial 

encounterS93.419D Sprain of calcaneofibular ligament of unspecified ankle–

subsequent encounterS93.419S Sprain of calcaneofibular ligament of unspecified ankleS93.431A Sprain of tibiofibular ligament of right ankle  ‐ initial 

encounterS93.431D Sprain of tibiofibular 

ligament of right ankle – subsequent encounter

S93.431S Sprain of tibiofibular ligament of right ankle – sequelaS93.432A Sprain of tibiofibular ligament of left ankle  ‐ initial 

encounterS93.432D Sprain of tibiofibular 

ligament of left ankle – subsequent encounter

S93.432S Sprain of tibiofibular ligament of left ankle – sequelaS93.439A Sprain of tibiofibular 

ligament of unspecified ankle ‐ initial encounter

S93.439D Sprain of tibiofibular ligament of unspecified ankle–

subsequent encounterS93.439S Sprain of tibiofibular ligament of unspecified ankle–

sequelaS93.491A Sprain of other ligament of 

right ankle (Internal collateral/talofibular) initial encounterS93.491D Sprain of other ligament of 

right ankle (Internal collateral/talofibular) subsequent 

encounterS93.491S Sprain of other ligament of 

right ankle (Internal collateral/talofibular) sequela

S93.492A Sprain of other ligament of left ankle, initial encounter

S93.492D Sprain of other ligament of left ankle subsequent encounter

S93.492S Sprain of other ligament of left ankle sequela

S93.499A Sprain of other ligament of unspecified ankle initial encounterS93.499D Sprain of other ligament of unspecified ankle subs encounter

S93.499S Sprain of other ligament of unspecified ankle (Internal 

collateral/talofibular) sequelaS96.211A Strain of intrinsic muscle and tendon at right ankle and foot level 

initial encounterS96.211D Strain of intrinsic muscle and tendon at right ankle and foot level 

subsequent encounterS96.211S Strain of intrinsic muscle and tendon at right ankle and foot level 

sequelaS96.212A Strain of intrinsic muscle and tendon at left ankle and foot level 

initial encounterS96.212DStrain of intrinsic muscle and tendon at left ankle and foot level 

subsequent encounterS96.212S Strain of intrinsic muscle and tendon at left ankle and foot level 

sequelaS96.219A Strain of intrinsic muscle and 

tendon at ankle and foot level, unspecified side initial encounter

S96.219D Strain of intrinsic muscle and tendon at ankle and foot level, unspecified side subs encounter

S96.219S Strain of intrinsic muscle and tendon at ankle and foot level, 

unspecified sideS96.811A Strain of other muscles and tendons at right ankle and foot level 

initial encounter S96.811D Strain of other muscles and tendons at right ankle and foot level 

subsequent encounter

S96.811S Strain of other muscles and tendons at right ankle and foot level 

sequelaS96.812A Strain of other muscles and tendons at left ankle and foot level 

initial encounterS96.812D Strain of other muscles and tendons at left ankle and foot level 

subsequent encounterS96.812S Strain of other muscles and tendons at left ankle and foot level 

sequelaS96.819A Strain of other muscles and 

tendons at ankle and foot level, unspecified side initial encounter

S96.819D Strain of other muscles and tendons at ankle and foot level, unspecified side subs encounter

S96.819S Strain of other muscles and tendons at ankle and foot level, 

unspecified side sequelaS96.911A Strain of unspecified muscle and tendon at right ankle and foot 

level initial encounterS96.911D Strain of unspecified muscle and tendon at right ankle and foot 

level subs encounterS96.911S Strain of unspecified muscle and tendon at right ankle and foot 

level sequelaS96.912A Strain of unspecified muscle and tendon at left ankle and foot level 

initial encounterS96.912D Strain of unspecified muscle and tendon at left ankle and foot level 

subs encounterS96.912S Strain of unspecified muscle and tendon at left ankle and foot level 

sequelaS96.919A Strain of unspecified muscle and tendon at ankle and foot level, 

unspec. side initial encounterS96.919D Strain of unspecified muscle and tendon at ankle and foot level, 

unspec. side subs encounterS96.919S Strain of unspecified muscle and tendon at ankle and foot level, 

unspec. side sequela

Information Patterns

ICD‐9 has been evolving over the past 25‐30 years:Changes not consistent throughoutDiffering levels of specificity across chapters

ICD‐10 attempts to standardize levels of specificity and make them consistent across chapters.ICD‐10 classifies conditions by the stage of treatment vs. the episode of care.

ICD‐9 has been evolving over the past 25‐30 years:Changes not consistent throughoutDiffering levels of specificity across chapters

ICD‐10 attempts to standardize levels of specificity and make them consistent across chapters.ICD‐10 classifies conditions by the stage of treatment vs. the episode of care.

ICD‐10 Codes and Descriptions ICD‐9 Codes and Descriptions

026.851 649.51

Spotting complicating pregnancy, first trimester Spotting complicating pregnancy, delivered

026.852 649.53

Spotting complicating pregnancy, second trimester Spotting complicating pregnancy, 

026.853 antepartum

Spotting complicating pregnancy, third trimester

026.859

Spotting complicating pregnancy, unspecified trimester

Information Patterns

More extensive vocabulary of clinical concepts, body part specificity, patient encounter information,   and other components from which codes are built. 

ICD‐9 Code and Description ICD‐10 Codes and Descriptions

87353 S01521A   Laceration with foreign body of lip, initial encounter

Complicated open wound  S01511A   Laceration without foreign body of lip, initial encounter

of lip S01521D   Laceration with foreign body of lip, subsequent encounter

S01511D   Laceration without foreign body of lip, subsequent encounter

S01541A   Puncture wound with foreign body of lip, initial encounter

S01531A   Puncture wound without foreign body of lip, initial encounter

S01541D   Puncture wound with foreign body of lip, subsequentencounter

Differences in Classification

Recommended Discovery Tasks for ProvidersJanuary to June 2011• Identify competing projects and determine the priority of

ICD-10.• Identify current systems that use ICD-9 codes.• Identify current reports that contain ICD-9 codes.• Identify current business processes that use ICD-9 codes.• Review vendor contract language to determine if ICD-10

system upgrades are required and included in contract.• Analyze business processes to identify changes required.

Recommended Discovery Tasks for ProvidersJanuary to June 2011 (continued)• Contact system vendors to determine if and when an

ICD-10 complete upgrade will be offered.• Analyze revenue and productivity impacts.• Assess staff training needs.• Estimate costs and budgetary implications.• Contact clearinghouses, billing services, and payers to

determine when they will be ready to test.

Recommended Planning Tasks for Providers

July – September 2011• Develop an implementation plan.• Identify assumptions and risks to

compliance.• Update encounter forms and other

forms.

ICD-10 on Provider Home Page of BCBSRI.com

ICD-10 Landing Page on BCBSRI.com

ICD-10 Noncompliance

• Your claims and other transactions may be rejected.

• You will need to resubmit them with the ICD-10 codes.

• This may result in delays in reimbursement.

Thank you!