California Medical Association

Tuesday, February 21, 2017

Transitioning to ICD-10

ICD-10 code sets will replace ICD-9 on October 1, 2015. Everyone covered by HIPAA is impacted by this change in code sets.

  • Claims for services provided on or after October 1, 2015 should be submitted with ICD-10 diagnosis codes
  • Claims for services provided prior to October 1, 2015 should be submitted with ICD-9 diagnosis codes
  • Changes to ICD-10 does not affect CPT coding for outpatient procedures

In order to effectively transition to ICD-10, providers should note the following differences between ICD-9 and ICD-10 and staff should be trained to ensure compliance with the new coding system.

SFMS has compiled the following information to assist our members with ICD-10 transition.

 ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

 No Laterality
Laterality - Right or Left account for >40% of codes

 3-5 digits

  • First digit is alpha (E or V) or numeric
  • Digits 2-5 are numeric
  • Decimal is placed after the third character

7 digits

  • Digit 1 is alpha; digit 2 is numeric
  • Digits 3-7 are alpha or numeric
  • Decimal is placed after the third character
No placeholder characters
"X" placeholders
14,000 codes
69,000 codes to better capture specificity
Limited Severity Parameters
Extensive Severity Parameters
Limited Combination Codes
Extensive Combination Codes to better capture complexity
1 type of Excludes Notes
2 types of Excludes Notes

Other Changes to Note in ICD-10-CM

  • Importance of Anatomy: Injuries are grouped by anatomical site rather than by type of injury.
  • Incorporation of E and V Codes: The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM.
  • New Definitions: In some instances, new code definitions are provided reflecting modern medical practice (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8 weeks).
  • Restructuring and Reorganization: Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM.
  • Reclassification: Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge.

Claims Submission

Providers should submit all claims with ICD-10 codes as of October 1, 2015. Claims for patient encounters prior to that date can be submitted using ICD-9 codes. CMS will not be denying claims based on specificity of codes as long as providers use the code from the right family. This policy is in effect for until September 30, 2016 at which time claims will need to have specific ICD-10 codes. Please note that claims can be chosen for review for other reasons.

Not Ready?

Providers that are having delays implementing ICD-10 have the following options to consider:

  1. Free Billing Software and Provider Internet PortalsClick here for the comprehensive list. These options apply to Medicare claims only.
  2. In some cases you may be eligible to use paper claims to meet the ICD-10 requirements. You can apply for a waiver of the Administrative Simplification Compliance Act (ASCA) by visiting the CMS website. The following requirements must be met to qualify for a waiver:
  • Software vendor is not ICD-10 ready
  • Your MAC’s providers internet portal does not support electronic claims submission
  • In either of the above scenarios you must prove financial hardship to switch vendors or billing services and provide the following:

    • Vendor letter stating their software is not ICD-10 compliant; OR
    • Attestation from provider stating that the software in use is not ICD-10 ready; AND
    • Attestation of provider financial hardship; AND
    • Acknowledgement that paper claims must be submitted in a machine scannable format.

    If a provider qualifies for the ASCA waiver they will be placed on a Corrective Action Plan (CAP) not to exceed 120 days. The provider must also submit a well-documented plan with timelines to become ICD-10 compliant.

    Additional Resources

    CMS has set up a center for communication and collaboration that began operation at the end of September. The center will identify and initiate resolution of issues providers face during this transition. William Rogers, MD, an emergency physician who heads CMS’ Physician Regulatory Issues Team, is the ombudsman. Rogers will serve as an internal advocate inside CMS and he will take questions and concerns at

    • On-demand ICD-10 webinar. Presented by the American Academy of Professional Coders (AAPC), the ICD-10: An Overview webinar provides an overview of specificity, dual processes, chronic conditions, medical policies and case examples. This webinar is free to SFMS members ($99 for non-members) and is intended as a final review for those who have a base knowledge of ICD-10.

    SFMS is the best in organized medicine. Our members are informed, connected to their communities, and care deeply about their patients. That’s why I’m a member!

    David Pating, MD, Health Commissioner for the City and County of San Francisco, and Chief of Addiction Medicine at Kaiser Medical Center, San Francisco

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