ICD-10 Diagnosis Codes & Procedure Codes

As your company plans the move from ICD-9 to ICD-10, now is a good time to examine whether you are planning for proper use of procedure codes.   ICD-9 based claims may or may not contain this data.  If you work with a health care provider and in particular a hospital, consider the possibility that providers will be required by payers on an increasing basis to include procedure codes on all claims in the future.  If you are a health care payer, these procedure codes and the analytics can help provide better information on reimbursement levels.   For both entities, procedure codes will impact contract renegotiations in the future.

One reason for this is that ICD-9-CM in some cases has a “not otherwise specified” (NOS) coding option. NOS options in ICD-10-PCS are restricted. A minimal level of specificity is required for each part  of a procedure.

The ICD-10 Procedure Coding System (ICD-10-PCS) succeeds Volume 3 of ICD-9-CM.  The new coding system uses 7 alpha or numeric digits while ICD-9-CM  uses 3 or 4 numeric digits. ICD-9 is over 30 years old and does not use current terminology or provide enough detail on the in patient’s medical condition or procedures performed.  We have heard from some companies that they believe that the move to ICD-10 will be easy because they will simply ask IT to lengthen the size of the fields which contain this data.  Unfortunately it isn’t that easy.

At times, an ICD-10 assessment by a knowledgeable third party can encourage different teams to improve communication and discover hidden assets that are under utilized.  It may very well be that valuable procedure code data is contained in the raw EDI files your company sends or receives, but it may not be stored or used for analysis.  Maximizing the use and analysis of existing data can strengthen your organizations’ planning and have a favorable revenue impact.

Indeed, payers should start requiring procedure codes and diagnosis codes on hospital claims to validate exactly what they are paying for.  We recommend to our clients that they begin a study to collect and analyze procedure code data from hospitals, and develop alternative reimbursement models based on ICD-10 codes, CPT, DRGs,etc.

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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