ICD-10: It's Here!
October 1, 2015 is here and with it comes the implementation of the tenth revision of the International Statistics Classification of Diseases and Related Health Problems (ICD-10)!
In 2009, Centers for Medicare and Medicaid Services (CMS) announced that a new set of diagnoses codes would be introduced into the nation’s healthcare system. When the announcement was made, there was an audible groan heard from physicians and their staff. It seemed we had only just learned ICD-9 and a new code set seemed unnecessary. Nevertheless, this new code set was introduced and the Health Insurance Portability and Accountability Act (HIPAA) covered entities were told that they would be required to comply. Health and Human Services (HHS) set an initial compliance date of October 1, 2013. Since that time, there have been two delays, but no additional delay has been announced. Beginning October 1, 2015, all healthcare providers will be required to report ICD-10 codes on all claims requiring a diagnosis code.
It is true that the medical field has been, and will continue to be, impacted by ICD-10 to a greater degree than the dental field. However, with the recent changes in healthcare regulations and in the insurance industry, many dental practices may find that they will also need to report ICD-10 codes on the 2012 ADA Dental Claim Form or a medical claim form.
As the October 1, 2015 implementation date arrives, many practices are being inundated with information on how to prepare for this new code set. The reality is that most dental providers do not know what an ICD-10 code is, the requirements for reporting ICD-10 codes, or how to properly select an ICD-10 code to report.
There are two different segments of ICD-10: ICD-10-PCS (Procedure Coding System) and ICD-10-CM (Clinical Modification). Only inpatient hospital claims use ICD-10-PCS. All outpatient encounters (including visits and treatments) use ICD-10-CM. In this article, every use of the term ICD-10 refers to ICD-10-CM.
What Does an ICD-10 Code Look Like?
ICD-10 contains approximately 69,000 codes, which may seem overwhelming. However, the truth is that all specialties, including dentistry, will only use a fraction of the available codes. In fact, most dentists will find that there are only a few codes they will use regularly. Let us take a look at the structure of ICD-10 codes and their usage in the dental office.
The ICD-10 code set is comprised of 21 chapters, each dealing with a specific part of the anatomy, type of disease, condition, symptoms, complicating factors, or effects of external causes. For each chapter there are specific reporting guidelines. Many codes found in Chapter 11, “Diseases of the Digestive System,” may be used to describe conditions of the mouth.
ICD-10 codes are alphanumeric and each consists of three to seven characters.
- The first character is always a letter. This letter signifies the chapter where the code is located.
- The first three characters of each code signify the code’s category.
- When a code is greater than three characters, a decimal point follows the third character, which is always
- The following three characters provide greater information, such as the severity of the condition or symptom and/or specifies the anatomic site.
Reporting a valid diagnosis code requires that all applicable characters be included. The different characters can become confusing. Let us review an example of the structure of a diagnosis code to describe dental cavities (caries) to clarify these different characters.
Category
K02 Dental caries
The letter K indicates this code is located in Chapter 11, “Diseases of the Digestive System.” The numbers “02” indicate this code relates to dental caries.
Specifics
K02.5 Dental caries on pit and fissure surface
Per the guidelines mentioned above, there is a decimal point following the first three characters. The number 5 indicates that caries are on the pit and fissure surface.
An additional character is also required, as follows:
K02.51 Dental caries on pit and fissure surface limited to enamel
K02.52 Dental caries on pit and fissure surface penetrating into dentin
K02.53 Dental caries on pit and fissure surface penetrating into pulp
K02.6 Dental caries on smooth surface
Per the guidelines mentioned above, there is a decimal point following the first three characters. The number 6 indicates the caries are on the smooth surface of the tooth.
An additional character is also required, as follows:
K02.61 Dental caries on smooth surface limited to enamel
K02.62 Dental caries on smooth surface penetrating into dentin
K02.63 Dental caries on smooth surface penetrating into pulp
K02.7 Dental root caries
Per the guidelines mentioned above, there is a decimal point following the first three characters. The number 7 indicates the caries are located on the tooth root. There are no additional characters required to further describe this condition.
K02.9 Dental caries, unspecified
Per the guidelines mentioned above, there is a decimal point following the first three characters. The number 9 indicates an unspecified area or extent of the caries. There are no additional characters required to further describe this condition. However, some payers may reject this code and require a more specific diagnosis to process a claim.
This code, while relatively simple, requires that the code reported be specific for the type of cavity treated. In coding terminology, this is referred to as “specificity.” This is a term you may hear often in relation to ICD-10; one benefit of this code set is the ability to report more specific and detailed information than was possible with ICD-9.
Codes requiring six characters will describe a condition in even greater detail. For example, when reporting a partial loss of teeth due to an accident, the applicable codes will be:
Category
K08 Other disorders of teeth and supporting structures
Guidelines state this code requires a fourth digit.
Specifics
K08.4 Partial loss of teeth
This code has a fourth digit; however, guidelines further instruct this code requires a fifth digit.
K08.41 Partial loss of teeth due to trauma
This code has a fifth digit; however, guidelines further instruct this code requires a sixth digit. The codes listed below offer the highest degree of specificity for this code. Only codes reported to the highest possible level of specificity will be accepted for claims processing. The codes below are the only valid codes for reporting this type of tooth loss.
K08.411 Partial loss of teeth due to trauma, class I
K08.412 Partial loss of teeth due to trauma, class II
K08.413 Partial loss of teeth due to trauma, class III
K08.414 Partial loss of teeth due to trauma, class IV
K08.419 Partial loss of teeth due to trauma, unspecified class
Some medical specialists, such as orthopedists, will find that another feature of ICD-10 is the requirement to report laterality. For example, when assigning a code for a wrist fracture, it is necessary to report a code that is specific to the right or left wrist. Although few, if any, dental related codes will require laterality, it is important to note that all codes must be reported to their greatest degree of specificity and laterality.
We have discussed the first six characters, but what about the seventh character? Certain categories contain codes requiring a seventh character. This is an extension of the code and is often used to describe a sequence of encounters, such as an initial visit or subsequent care. These are most often found in Chapter 19, which includes codes pertaining to injury, poisoning, and certain other consequences of external causes, and Chapter 15, which includes codes pertaining to pregnancy. When a seventh character is required, the code is not valid unless it is reported.
Sometimes the seventh character is required for a diagnosis code, which otherwise would be comprised of five characters or less. In this case, the missing character(s) are replaced with the placeholder, “X.” The concept of placeholders is unique to ICD-10 and creates a space for possible expansion of these codes. An example of a code that requires both placeholders and a seventh character is:
S02.5XXA Fracture of tooth (traumatic) initial encounter for closed fracture
The letter S indicates this code is from Chapter 19, “Injury, Poisoning and Certain Other Consequences of External Causes.” The numbers “02” indicate that this code relates to a fracture of skull and facial bones. Note that there are four characters following the decimal point. The number five indicates a fractured tooth, followed by two placeholders. The seventh character is the letter “A,” which in this case indicates this is the initial visit for a closed fracture.
This may seem confusing, but it is actually pretty simple. All code listings indicate where this placeholder is located in the code. If you are using an ICD-10 coding manual to locate your diagnoses codes, you will find guidelines in each chapter indicating when a seventh character is required. Furthermore, these codes clearly indicate each code and the required specificity.
Will Dentists be Required to Report ICD-10 Codes?
You may be wondering if ICD-10 is something you need to learn. Once ICD-10 is implemented, all claims requiring a diagnosis code will require that ICD-10 codes be used. If you never report diagnoses codes on your claims, then you may be minimally affected by ICD- 10. It is important to note, however, that there are changes in the healthcare and insurance fields, which may necessitate the use of diagnoses codes in the near future. The potential changes include the following:
- CMS has mandated that ICD-10 be implemented for all HIPAA covered entities. This includes state Medicaid plans and affects Medicaid dental claims in some states.
- Some Affordable Care Act (ACA) plans currently require a diagnosis code on dental claim forms submitted for charges under the mandated pediatric dental benefits.
- Many dental payers are now requiring that claims for surgical extractions be filed under the patient’s medical plan.
The January/February 2015 issue of Insurance Solutions Newsletter published an article titled “Diagnostic Coding: The New Reality for Dentists” that outlined these requirements and their effects on the dental practice.
What should I do to prepare?
With the understanding that most dentists will eventually need to report a diagnosis code, the following basic steps are advised:
- Check with your software vendor. This may be the single most important action you can take. As already noted, many practices rarely submit a diagnosis code. If you suddenly find the need to report a diagnosis code on a specific claim, locating the code is relatively easy. If your software is not capable of creating a claim to include a diagnosis code, this could cause a significant delay in reimbursement. Your software vendor should be prepared to accommodate the 2012 ADA Dental Claim Form, thus allowing the reporting of ICD-10 codes.
- Become familiar with the most common codes used in the dental practice. You do not have to be an expert coder to understand the basics of how a diagnosis code is assigned. There are both printed and online sources for ICD-10 codes, such as www.icd10data.com. Be aware that all sources are not developed specifically for the dental practice. Read code descriptions carefully to determine the most accurate code to report in each circumstance.
- Review your clinical documentation. Accurate and complete documentation is critical for many reasons, including the continuity of patient care. As we have discussed, ICD-10 requires very specific information from the clinical notes, not a verbal discussion with the dentist. Thorough, complete, and concise documentation will help ensure not only excellent care for your patients, but will assist in correct reporting of diagnoses codes.
Gaining Confidence
This is only a brief overview of ICD-10 codes and their impact on the dental practice. Familiarizing yourself with the medical coding basics is only the first step in expanding your knowledge of the new ICD-10 codes. As with any other challenge, this is best met by learning and applying each concept one at a time. By beginning to identify and understand those codes common to your practice, you will soon become proficient in correctly reporting diagnoses codes.