ICD-9-CM and ICD-10-CM

Some Differences and Similarities

CMS is stating they expect 10% of all claims submitted to be denied with ICD-10 initially. Selecting and assigning accurate diagnoses in the proper sequence must be performed in compliance with Medicare rules and regulations, Coding Conventions and Coding Guidelines. That remains the same.

The accuracy of this information contained in the clinical record is directly tied to payment and to justification for homecare services, so understanding how to select and assign accurate diagnoses is very important. This is the same but the specificity of the documentation becomes very very important. Increased specificity in data means more robust design of algorithms to predict outcomes and care by MACS, RACs, and Z-PICs.

ICD-10-CM presents an even greater challenge for documentation by the clinician. The word “documentation” is stated 72 times in the ICD-10-CM guidelines document.  Querying for additional information is noted 23 times in the same document. The instructions and conventions of the classification take precedence over guidelines which requires a keen understanding of the conventions.

ICD-10 requirements have raised the documentation expectations

Have your clinicians had an overview of ICD-10-CM? Here are just some observations.

  • Coding assignment will be based on the agency’s documentation of the relationship between the condition and the care that is planned.
  • Not all conditions that occur during or following surgery will be classified as complications
  • A cause and effect relationship must be present between the care provided and the condition clearly delineated within the documentation
  • Query for Clarification re documentation that supports codes assigned is expected
  • There will be specific documentation needed for specific codes and without the documentation, the codes may not be used
  • Code only those diagnoses that are relevant, unresolved, and impact the plan of care. Diagnoses that are resolved or have no impact on the plan of care should be excluded since they do not meet the criteria for a home health diagnosis
  • Code only those diagnoses that are supported by the medical record including diagnoses supported by the plan of care and the comprehensive assessment.
  • There are placeholders in ICD-10
  • There is laterality
  • There are sixth and seventh characters
  • ICD-10 requires expertise in anatomy, physiology, diagnostics, and pharmacology

Agency clinicians are expected to understand the patient’s clinical status and overall medical condition very well before approving/assigning diagnoses, so the comprehensive assessment must be ­completed in its entirety prior to the diagnoses decision. All coders should be properly educated on ICD-10-CM including how to use coding manuals properly. 50 + hours are being identified as necessary for each coding specialist to be properly prepared for ICD-10.

Your agency’s integrity and financial health could well depend on your preparation for ICD-10. Selecting and assigning accurate diagnoses must be performed in compliance with Medicare rules and regulations, in addition to ICD-10-CM coding guidelines.

You have choices; either prepare VERY VERY well for ICD-10 or consider third party experts for coding and remove that burden and concern.