On October 1, 2015, CMS will adopt the International Classification of Diseases, Tenth Revision (ICD-10) for diagnosis coding. Due to the next level of specificity that ICD-10 codes entail as it relates to parts of the human body, Medicare will be able to more definitively process claims it receives for payment of Medicare covered health services and any associated “lien” or secondary payer recovery actions. The transition to ICD-10 will greatly affect parties involved in personal injury settlements and CMS by allowing settling parties to more impactfully dispute Medicare lien amounts and by giving CMS a much needed tool to accurately identify medical services related to an underlying tort-related injury and lien amount.

In the coming weeks, GRG will provide stakeholders with a “case study” demonstrating the potential impact the transition to ICD-10 may have on settling parties. For now, with the transition being close to its final implementation, GRG has compiled a few items to help you understand the potential impact of the transition and ways in which ICD-9 and ICD-10 diagnosis codes differ:

  • The Number of Codes: ICD-9 has roughly 14,000 diagnosis codes and nearly 4,000 procedural codes. In comparison, ICD-10 contains over 68,000 diagnosis codes and over 72,000 procedural codes (with room for expansion). The large increase in diagnosis and procedural codes reflects just how complex and specific the coding can be.
  • Specificity: ICD-9 is lacking in its ability to identify specifics in injuries. For example, the same injury on opposite limbs is the same ICD-9 code with no indication of left limb versus right limb. This reduces effectiveness, especially in lien resolution where many hours can be wasted disputing erroneous claims that Medicare is attempting to recover. ICD-10 does offer a greater degree of specific information, which should enhance Medicare’s ability to correctly identify recoverable claims, and potentially expedite the claims review and audit process. Areas such as initial or subsequent encounters, right versus left, and other relevant information can be expressed through ICD-10 diagnosis codes, as well.
  • Alphabetic and Combination Codes: One of the reasons ICD-9 codes were so limiting was due to the fact that it only permitted numeric codes. In contrast, ICD-10 makes significant use of alphabetic codes in order to be more specific. Further, ICD-10 supports use of combination codes that will be used in the classification of multiple diagnoses or a diagnosis with complication.

It is also important to know how the adoption date of October 1, 2015 affects your practice. When October 1, 2015 comes, it does not necessarily mean that you will have to start implementing the use of ICD-10 codes. Instead, the use of ICD-10 codes becomesmandatory for cases whose Date of Injury (DOI) occurred on or after October 1, 2015. Any case involving a DOI that occurred before October 1, 2015 may continue to make use of the ICD-9 codes you are currently using. This consideration may be especially important for defendants and liability carriers proceeding with their standard MMSEA reporting protocols, but is equally important to plaintiffs disputing Medicare lien amounts, as existing standards of practice must be modified.

In summary, the implementation of ICD-10 has very tangible benefits: the ICD-10 codes will allow Medicare to precisely identify its reimbursement claims, thereby potentially reducing time spent on disputing liens. Due to the expansion and complexities of ICD-10 diagnosis codes, however, those involved in the resolution of Medicare’s reimbursement claims must devote the time to properly train and educate their staff on the accurate use of ICD-10 diagnosis codes and update existing resolution protocols accordingly.

Stay on the lookout for the GRG ICD-10 Case Study in the coming weeks, and find out how to stay ahead of the ICD-10 and other health care compliance curves when it comes to all your Medicare Compliance needs at

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