Begin to apply ICD-10 in real-life practice

CMS has begun to apply ICD-10 coding standards more concretely, such as adding them to future versions of its coverage policies.

Until now, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) codes have been mostly a theoretical construct. We've heard and read about them, but they hadn't actually been applied to everyday coding situations. Now, CMS is beginning to apply ICD-10 in a more concrete manner, such as adding it to future versions of its coverage policies.


In preparation for the ICD-10 transition, CMS has revised many of its National Coverage Determination (NCD) documents by replacing the ICD-9 codes with appropriate ICD-10 codes. CMS has also instructed its claims contractors to begin updating their claim system edits with the revised diagnosis codes, to go into effect on Oct. 1, 2014.

The NCDs, one of the coverage communication tools used by the agency, are “... national policies on the coverage of specific medical services. Both the local and the national coverage processes explicitly consider whether services meet Medicare's statutory requirements for ‘reasonable and necessary’ care,” according to a Medicare Payment Advisory Commission publication.

An NCD contains, among other components, the medical condition under focus, the Current Procedural Terminology (CPT) code(s) describing medical interventions for it, and the covered ICD diagnosis codes that correspond to descriptions of the permutations of the medical condition. In this revision project, the longstanding ICD-9 codes are currently being revised; ACP is not aware of any accompanying revision of the coverage decisions. All NCDs will need to include ICD-10 codes next year.

In early 2013, CMS released a list of 30 revised NCDs; overall, there are over 300 existing ones. Clearly, the agency has a way to go before they finish revising all the NCDs. Physicians and their coders can use these determinations to begin thinking about how they will adjust their own coding to include ICD-10. The full list of revised NCDs can be found online.

Of the 30 revised NCDs, the following are relevant to internal medicine:

  • percutaneous transluminal angioplasty,
  • cardiac output monitoring by thoracic electrical bioimpedance,
  • intensive cardiac rehabilitation programs,
  • diabetes outpatient self-management training,
  • outpatient intravenous insulin treatment,
  • histocompatibility testing,
  • home prothrombin time/international normalized ratio monitoring for anticoagulation management,
  • smoking and tobacco use cessation counseling,
  • counseling to prevent tobacco use,
  • screening for HIV infection, and
  • screening for sexually transmitted infections and high-intensity behavioral counseling to prevent sexually transmitted diseases.

Table presents an example of the ICD-9 versus ICD-10 diagnosis codes, as found in one of the revised NCDs.

Notice that in ICD-9, there is only one diagnosis code to use for tobacco use disorder: 305.1. But in ICD-10, the range of diagnosis codes (F17.200 through F17.291) can specify whether the patient's nicotine dependence is in remission and can also specify the type of nicotine product used. As with ICD-9 coding, the new ICD-10 coding will require complete documentation and will also encourage physicians to code to the highest level of specificity.

Twinned diagnosis codes

News stories about the ICD-10 external causes codes began popping up about a year ago. The codes describe unusual causes of injuries. Particular codes can be humorous (unless you happen to be the patient who had the accident), but in most cases there is no confusion about what the code represents.

In ICD-10, these codes begin with the letters “V” through “Y”; in ICD-9, they begin with the letter “E.” These E codes could cause confusion during the overlap period of ICD-9 and ICD-10 claims, because there is a set of ICD-10 codes that duplicate some of the ICD-9 E codes but mean entirely different things.

Claims submitted and processed during the expected overlap period (August 2014 through December 2014) will absolutely need to indicate which diagnosis code set is referenced. Otherwise, some claims might be denied unnecessarily. However, one would expect that for dates of service on or after Oct. 1, 2014, the code interpretation should be ICD-10.

Cigna Health Plans identified a small number of such codes (see Table 2).

ACP will continue to provide its members with information about ICD-10 coding. Other resources include: