What is ICD-10?

ICD–10 is the acronym for The International Classification of Diseases – 10th Revision. This is the massive compilation of diagnosis codes (ICD–10–CM) and inpatient procedure codes (ICD–10-PCS) used for clinical illness documentation and claims filing by providers and facilities. ICD-10 replaces ICD-9 that has been in use since 1979. The most significant differences between the two are:


ICD-9-CM VOLS. 1 & 2


Available codes

Approximately 14,000 codes

Approximately 69,000 codes

Field length

3-5 characters

3-7 characters

Code composition

Digit 1= alpha or numeric

Digit 2-5 = numeric

Digit 1 =alpha

Digit 2 = numeric

Digit 3-7 = alpha or numeric

Capacity for new codes



Embedded detail


Highly specific


Right versus left side not identified

Side often identified

Sample code illustration

923.11 Contusion of elbow

S50.01XA Contusion of right elbow, initial encounter

The characteristic found in ICD-10-PCS are very similar to those found in ICD-10-CM.

Based on the greater volume of codes and their precise definitions, ICD-10 seeks to refine healthcare information and patient care by improving reporting and data mining capabilities.  Payers will seek to utilize it to transition from volume-based to outcome-based claim reimbursement policies.

When is the ICD-10 compliance due date?

All HIPPA covered entities must begin ICD-10 utilization on October 1, 2015

What are the potential risks of non-compliance?

Each day that passes, for the next 12 months or so, the ICD-10 non-compliance risks grow and become more relevant to the practice.  Although difficulties from non-compliance will surface on numerous levels, regulatory, training, clinical documentation, loss of productivity, operational challenges, IT software and structure, outside vendors, direct implementation expenses, etc.  They will all contribute to the same impact on the practice – LOSS of REVENUE.

In the United States, where the healthcare system is based mostly on the capitalistic model, any loss of revenue (even 10%) for the practice could be substantial enough to threaten its survival. If you do not start preparing your practice for the ICD-10 transition now, the project will become overwhelming and you will be non-compliant after October 1, 2015.  You will start to LOSE REVENUE!

What are the ICD-10 transitional challenges to your practice operations?

  • Regulatory - All claim submitters must use ICD-10 codes starting October 1, 2015. Additionally, before any ICD – 10 claims can be sent, submitters first need to ensure their software is running the Version 5010 transaction standards mandated by HIPPA.
  • Clinical documentationClinical documentation must support all billing diagnoses. To achieve this mandate providers and patient intake staff will need the awareness, training, and access to the means for properly documenting clinical illness presentations and the circumstance of treatment. In turn, billers need to ensure consistency between claims information and clinical documentation.   
  • Patient care/disease and case management – Practices will have to adapt to ICD-10 illness descriptions in order to secure authorizations for treatments, referrals coverage eligibility, benefit determinations and comply with payers’ medical policy requirements.
  • Operational protocolsIn order to facilitate proper ICD-10 coding, more detailed information must be obtained from each patient.  In-take questionnaires should accommodate ICD-10 descriptive precision and be completed by the patients. In-take staff should review. Diagnoses provided by referring physicians should be considered and documented. Providers and their clinical staff should document patient charts, progress notes, and treatment plans using crosswalk tools or preferably native coding assessments.
  • Claim coding/claim rejections/claim follow-up Claims with conditions not coded properly or to the highest level of ICD-10 specificity will reject on various levels and may ultimately deny for reimbursement. As a result, precious time will be wasted on additional follow-up, research, payer contact, corrected claims, and/or appeals.
  • Billing/EHR software adaptability and structureThe additional volume and complexity of the ICD-10 code set will be an extremely difficult to task for practices to handle without the computerized assistance from practice management and/or billing systems, and EHR systems.  Providers, billers, and intake staff will need access to these systems to properly code from the ICD-10 set. Management’s responsibility is to ensure these systems have user friendly ability to minimally search for codes base on:
    • Terms found within the code descriptions
    • Multiple code ranges, partial code ranges
    • Published tabular index
    • Alphabetic index
    • Speech recognition
    • Crosswalk between ICD-9 and ICD-10
  • Vendor/Payer unpreparedness and or unresponsivenessPractice management will have to verify that all relevant vendors have updated their systems to handle the transition to ICD-10. Such vendors will minimally include suppliers of practice management/billing systems, coding programs, clearinghouses, insurance payers.  Any lagging on the vendor side can spell disaster for cash flow.
  • Provider/Staff trainingPractice management should assess the training needs of their staff. As with any training, it is based on the need to know and the operational structure within the practice. Generally, coders and providers will need the most training on ICD-10 (16 and 12 hours respectively) while intake staff and billers will need about 8).
  • Lack of timeAny change involving the complexity and size of the ICD-10 transition will demand additional time for accommodation.  Practice management may well see up to a 20% increase in ICD-10 documentation activities and a permanent increase of up to 4% in time spent by the provider on documentation (as reported by L. Law and M. A. Porucznik in AAOS Now). This means there will be less time to do everything that needs to be done.
  • Loss of productivity on all levelsGiven ICD-10’s huge learning/adaptive curve and the much higher time demand it will impose on practice resources, the initial loss of productivity will be significant.  To help minimize the negative impact on cash flow and avoid operational chaos, immediate analysis, planning, and issue remediation is required.
  • Direct implementation expensesEven though the ICD-10 transition has been delayed a number of times, the extra time provided will not diminish the real dollar cost of its implementation. Experts in the industry predict costs will vary with the size and circumstances of each entity but that practices can expect to spend thousands of dollars to make the transition happen.  Prudence dictates the need for cash and/or credit reserves of up to 30% of the first year’s operating budget.
  • Lower reimbursement levels and restrictive payment policiesOn top of all the ICD-10 cash flow challenges within the practice, predictably there will be similar effects on cash flow from claim payers.  Claim reimbursement levels may potentially drop as denials increase as payers deal with translation/interpretation issues related to patient policies, benefits and their payment rules. This will be indicative of the overall difficulty payers will have processing claims in the new ICD-10 environment. Reimbursements from capitation and case-based model plans as well as other care plans based on episode, performance, or accountable-care metrics can also potentially drop as payers take the opportunity to reassess and readjust their risks relative to the new ICD-10 environment.
  • Increased Payer audits and recoupmentHaving a highly precise, descriptive, and voluminous coding set as a reimbursement baseline, payers will predictably use this as an opportunity to conduct verification audits.

How can Advantage Medical Billing help your practice navigate around the ICD-10 transitional difficulties?

For over 21 years, Advantage Medical Billing has been helping practices navigate the complex regulatory waters of the healthcare industry and successfully face the challenges of their medical billing. With the ICD-10 compliance deadline looming less than 12 months away, we urge you to start preparing for the transition now.

Collaborating with us is probably the best way to approach the ICD-10 transition project.  Since we are one of the foremost revenue management companies, we can assist in structuring a transition plan highly tuned to your specific circumstances.  Our auditing and best practices skills will assess your practice environment, operations and personnel to determine the scale of your transition project and the work necessary to achieve production readiness on or before the compliance deadline.  Our revenue management software, coding tools and methodologies will help facilitate correct coding, documentation and billing. Not only will you feel comfortable in your ability to comply with and survive in the ICD-10 environment, the advantages of having the best billing services available will be yours.

Our mission, just like yours, is to save your cash flow

Call us today to Get Ready Get Set …and GO

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