ICD-10 will require more precision in documenting visits

ACP staff answers questions that have arisen as members ramp up their efforts to comply with the new implementation standards.

ACP continues to urge its members to continue their progress toward ICD-10 readiness. There are only 6 months remaining to meet the Oct. 1 deadline. Failure to do so will mean claim payment delays and revenue stream disruptions. If you're not sure what planning stage your practice should be in, please refer to the ACP Physician & Practice Timeline online.

During the ramp-up to ICD-10 implementation, ACP has provided a number of resources to its members. In the course of discussions with individual members, some questions arise repeatedly.

Q: We are hearing new rumors that ICD-10 implementation will be delayed again. Is this true?

A: ACP has neither seen nor heard any indication of a further delay. In fact, on Feb. 27, CMS Administrator Marilyn Tavenner stated, “There will be no change in the deadline for ICD-10.” Ms. Tavenner emphasized that the system has already been delayed too many times and that CMS solicited volunteers to participate with CMS in end-to-end testing of the new system in March.

Q: Is the switch to ICD-10-CM diagnosis coding really required? And if so, who mandates it?

A: Caution: alphabet soup ahead!

In 1996, Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191. Its purpose is to improve the efficiency and effectiveness of the health care system, and it includes the Administrative Simplification provisions, which require the U.S. Department of Health and Human Services (HHS) to adopt national standards for electronic health care transactions (electronic claims, remittance, enrollment acknowledgements, etc.), unique health identifiers, security and medical code sets.

The implementation date was first introduced in federal regulations in 2009, but implementation was delayed twice. On Aug. 24, 2012, HHS issued a final rule mandating compliance with the new, ICD-10 code set (the International Classification of Diseases, 10th Revision) by Oct. 1, 2014.

The currently mandated medical code sets include the Healthcare Common Procedure Coding System (HCPCS). When HIPAA mandated standard code sets, it combined the Current Procedural Terminology (CPT) and HCPCS into a 2-level code set. Now, HCPCS consists of Level 1, the CPT codes, and Level 2, the “traditional” HCPCS codes. The mandated medical codes also include the National Drug Codes (NDC), Current Dental Terminology (CDT), and International Classification of Diseases, 9th Revision (ICD-9).

If you're feeling adventurously wonkish, all of the HIPAA Administrative Simplification Rules are located at 45 CFR Parts 160, 162 and 164, online.

Q: How do medical staff begin navigating through the vast number of ICD-10 codes?

A: The codes are arranged in categories that are similar to those found in ICD-9.

The categories are as follows, with the code ranges shown in parentheses:

  • certain infectious and parasitic diseases (A00-B99),
  • neoplasms (C00-D49),
  • diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89),
  • endocrine, nutritional and metabolic diseases (E00-E89),
  • mental, behavioral and neurodevelopmental disorders (F01-F99),
  • diseases of the nervous system (G00-G99),
  • diseases of the eye and adnexa (H00-H59),
  • diseases of the ear and mastoid process (H60-H95),
  • diseases of the circulatory system (I00-I99),
  • diseases of the respiratory system (J00-J99),
  • diseases of the digestive system (K00-K95),
  • diseases of the skin and subcutaneous tissue (L00-L99),
  • diseases of the musculoskeletal system and connective tissue (M00-M99),
  • diseases of the genitourinary system (N00-N99),
  • pregnancy, childbirth and the puerperium (O00-O9A),
  • certain conditions originating in the perinatal period (P00-P96),
  • congenital malformations, deformations and chromosomal abnormalities (Q00-Q99),
  • symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99),
  • injury, poisoning and certain other consequences of external causes (S00-T88),
  • external causes of morbidity (V00-Y99), and
  • factors influencing health status and contact with health services (Z00-Z99).

Adjusting documentation

Using the codes is important for a practice's claims and revenue stream, but having someone on staff who understands the coding rules is every bit as important. The coding conventions are detailed in the ICD-10 book, and there are general tips for ICD-10 documentation that will improve the process.

  • The physician may need to provide greater clinical detail; the new codes are updated to address conditions and diseases seen in current medicine.
  • The physician should specify laterality, when needed. There are specific codes related to the site of the patient's condition, disease or injury.
  • For pressure ulcers, the location and stage should be documented.
  • Complications of care should be clearly documented.
  • The patient's body mass index should be included when relevant, and then referenced as a secondary, not primary, diagnosis.
  • The correct selection of combination codes will depend on the documentation of causal relationships.

For example, in ICD-10, the documentation must indicate the cause of anemia, the type and the acuity, as follows:

Cause of anemia

  • chronic anemia secondary to malignancy,
  • chronic anemia secondary to chronic kidney disease,
  • acute blood loss anemia secondary to acute gastrointestinal bleed,
  • acute post-operative blood loss anemia (if greater-than-expected blood loss during surgery), or
  • chronic idiopathic anemia

Type of anemia

  • iron deficiency,
  • pernicious,
  • aplastic,
  • sickle cell, or
  • blood loss anemia


  • acute,
  • chronic, or
  • acute on chronic

ACP will continue to provide members with information to ease their transition to ICD-10. Please refer to online documents at the College's Running a Practice website.