ED Coding and Reimbursement Alert

Advice saves you time and headaches researching ICD-10 answers.

Question: When will I need to start using ICD-10 codes?

Answer: All services and discharges on or after Oct.1, 2013 must be coded using the ICD-10 code set. This means that the work to assure your system modifications and staff training need to be tested and in place on Oct. 1, 2013.

Answer: Any ICD-9 codes for services or discharges on or after Oct.1, 2013 will be rejected and the claim will not be processed. This means your claims and payment will not be processed. If you believe your practice won't be ready, you will need to make financial arrangements to support the expenses of your practice until you can comply with the ICD-10 requirements.

Answer: Medical necessity will be determined for payment by payers with a totally new set of codes and guidelines. Inaccurate coding will be costly to the practice and facility. Providers will require a much higher degree of specificity in their documentation. Documentation of history and physical examination will require a higher level of specificity. Interdepartmental collaboration is critical.

Common ED diagnoses, such as chest pain, abdominal pain, altered mental status, respiratory complaints, or extremity pain/injury, will require a new way of thinking about documentation AND coding.

General Equivalence Mappings (GEMS) were created by CMS and the CDC to ensure that the consistency of national data is maintained. GEMS will be maintained for three years beyond the Oct.1, 2013 implementation date for ICD-10. GEMS will not take the place of ICD-10 education but it will assist with conversion of ICD-9 databases to ICD-10. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, to assure tracking quality; recording of morbidity/mortality; calculating reimbursement; and converting any ICD-9-CM-based application to ICD-10-CM/PCS. CMS has made a commitment to update the GEMs annually along with the updates to International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) and Procedure Coding System (PCS) during the transition period prior to ICD-10 implementation. CMS and CDC will maintain the GEMs for at least three years beyond October 1, 2013, which is the compliance date for implementation of ICD-10 for all covered entities, says Edelberg.