ICD-10 Codes and More: Interview with John Burns, Certified Professional Coder
Douglas L. Beck, AuD, speaks with Burns about Medicare, Congress, ICD-9, ICD-10, ICD-11, and more.
Beck: Hi, John. I know you have many unusual and interesting credentials and training with regard to billing and coding. As such, let's start by briefly reviewing your qualifications as a billing and coding expert?
Burns: When I completed my studies in health science, I moved to Atlanta and began working for a consulting firm that required certain credentials to serve its clients. I obtained my certified professional coder (CPC) certification first and then worked to become a certified instructor with the AAPC (CPC-I). As I became more involved in helping physicians and other health-care providers though audits and educational efforts, I began to realize the need to master evaluation and management (E&M) coding; a set of codes that were obviously subject to more scrutiny than other types of service. That was the reason I decided to obtain the Certified Evaluations and Management Coder (CEMC) credential. And then once the AAPC launched its Certified Professional Medical Auditor (CPMA) credential, I knew it was something that a consultant in my line of work simply needed to demonstrate the requisite skills necessary to audit medical claims and assist providers during payer pre-payment and post-payment reviews processes.
Beck: Thanks, John. I'd like to learn a little bit about the ICD-9 and ICD-10 issues. First of all, what does ICD stand for?
Burns: International Classification of Disease (ICD). ICD-10-CM is simply the 10th Clinical Modification. ICD dates back to the 1890s and was primarily intended to track mortality around the world. I first heard of ICD-10 back in the mid-1990s. It has been used in most industrialized nations since as early as 1994 and was set to take effect in the United States on October 1, 2015, after multiple delays. On July 6, 2015, CMS announced a one-year lenience period where Medicare will not audit ICD-10 and will process claims in a non-punitive manner so long as the codes selected are in the ballpark, so to speak.
Beck: Okay, and so ICD-10 seems to be on-again/off-again. No news there! When was ICD-9 implemented, and when do you think ICD-10 will finally be launched?
Burns: ICD-9-CM was introduced in the mid-1970s but was not necessary on physician claims for reimbursement until 1988. You see, professional physician services are paid based on relative value units (RVUs), not diagnostic parameters. Unlike hospitals and facilities (e.g., DRGs), the ICD-9-CM codes are simply used to describe "why" providers have performed a service and assist in establishing the medical necessity for service(s) performed.
Beck: And I understand there already exists an ICD-11...how is that possible and what is that all about?
Burns: Essentially, ICD-11-CM will be very similar to ICD-10-CM but simply a newer clinical modification. Don't worry, 8th, 9th, and 10th characters are not coming. I've been told (without any means to confirm at this point) that ICD-11-CM will introduce a 22nd chapter. The manual ICD-11-CM will be a digital product that supports electronic health records and information systems.
Beck: Wait! Hold on—What is a 22nd Chapter? And to be clear, did you say the change from ICD-10 to ICD-11 is essentially simply a digital change? And assuming yes…what does that mean?
Burns: Good pick-up, Doug. Currently in the ICD-9-CM, there are 17 chapters, in ICD-10 there are 21 chapters, and we're told that when ICD- 11 hits, a 22nd chapter will be added…so that's a relatively small change, but we'll have to wait and see. And as far as the change from ICD-10 to ICS-11, those two are expected to be very much the same, in terms of code structure and content, but there will be updated version, essentially a clinical modification.
Beck: Okay, so back to the immediate issues…What are the major differences we'll see between ICD-9 and ICD-10?
Burns: There are many differences between the code sets. ICD-9-CM contains roughly 13,000 codes when compared to the nearly 69,000 codes in ICD-10-CM. This is due in large part to the introduction of laterality coding concepts (left, right, bilateral, unspecified), combination codes, expansion of injury codes and external causes.
Beck: So then, would that mean that given ICD-10, we're actually going to code each ear for hearing and balance tests?
Burns: Anytime there is code that speaks to a bilateral anatomic structure, that code would be used rather than using one for each side. For example, there is currently one code in the ICD-9-CM to represent noise induced hearing loss, but of note, there are four options in ICD-10.
Beck: And although it's speculative, what would you think the general trend for ICD-10 reimbursement will be? I suspect none of us will be seeing increases in reimbursement? Is there a rough idea or estimate as to what percentage of lower payments we'll see across the board?
Burns: I think it's safe to say that reimbursements are not going to increase. I do, however, believe that payers will be provided more latitude in terms of denying claims when unspecified codes are assigned.
Beck: And so, if I were to guess, and I'm not trying to be snarky here…it seems the motivation for the ongoing delays in implementing ICD-10 is purely political. That is, if CMS were to reduce the reimbursements to all of us who accept Medicare and Medicaid, you'd have millions of annoyed healthcare professionals, and that could significantly influence the upcoming political season!
Burns: You're right. It is very political. Those issues are decided at the congressional level, and of course, I cannot speak to the specifics.
Beck: Okay, John, fair enough. Thanks for the updates. I appreciate your time!
Burns: Be well my friend!
NOTE: Are you prepared for the October 1, 2015, transition to ICD-10? Visit the ICD-10 section of the Academy's Web site (http://www.audiology.org/practice_management/coding/international-classification-diseases-10th-edition) to find important audiology-related resources related to this transition, including a list of ICD-10 codes pertinent to audiologists, implementation guides, and other requirements and deadlines.
John Burns is a Certified Professional Coder (CPC), Certified Instructor with the AAPC (CPC-I), Certified Evaluations and Management Coder (CEMC), and Certified Professional Medical Auditor (CPMA). He is also a senior consultant/approved NAMAS instructor with the Department of Audit and Regulatory Compliance.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology and the director of public relations with Oticon, Inc.