Charles Root, PhD

Following the October implementation of the ICD-10 medical coding system, how might labs work with physicians to ensure they use the proper codes?

If physicians submit laboratory requisitions with ICD-9 codes, the laboratory should contact them and remind them that only ICD-10 codes are now acceptable for all Medicare and commercial payer claims that the lab submits. Explain that in cases where the conversion from ICD-9 to ICD-10 is unambiguous—that is, when a one-to-one conversion exists—the laboratory will convert the unacceptable ICD-9 code to the correct ICD-10 code. However, in cases for which a simple one-to-one conversion is not possible, the lab will have to contact physicians for the correct ICD-10 code. Encourage them to avoid these follow-up calls by providing ICD-10 codes on the requisition—or as a last resort, ask physicians to provide a detailed narrative description that would enable the laboratory’s coders to accurately assign the correct ICD-10 code.

What should labs do if Medicare does not reimburse them because the ordering physician did not use the appropriate ICD-10 code?

If a laboratory submits an ICD-9 code on a claim after October 1, 2015, the claim will be returned as unprocessable. Thus, the only recourse is either to convert the ICD-9 to an ICD-10 (if possible, as noted above) or to contact the ordering physician and obtain an accurate ICD-10 code.

How does one convert ICD-9 codes to ICD-10 codes?

The General Equivalence Mappings (GEM) files for both ICD-9 to ICD-10 and ICD-10 to ICD-9 are available online from Medicare and numerous other sources. Merely search for “Medicare ICD-9 GEM” via Google or another search engine. These files tell you whether a given code is directly equivalent to a single code, multiple codes, or only approximately equivalent to one or more codes. Directly equivalent conversions that are unambiguous can always be used to convert ICD-9 codes to ICD-10. When the conversion is not one-to-one, you will usually have to contact the referring physician for additional information in order to assign the correct code.

For example, ICD-9 code 401.1, essential hypertension, benign, translates directly to ICD-10 code I10, essential (primary) hypertension. On the other hand, ICD-9 code 250.50, diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled, relates to the following four ICD-10 codes which can not be accurately assigned without additional information about the patient from the ordering physician:

• E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

• E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

• E11.36 Type 2 diabetes mellitus with diabetic cataract

• E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication

How should labs determine the specificity of a code?

The full code description must be used to assign a code. All alpha-numeric characters must be reported or the code will be rejected. When a series of codes apply to similar disorders or conditions, the code for the patient’s exact condition must be used or else a code describing the condition as “unspecified.”

Will labs see benefits from ICD-10 once the healthcare system adjusts to its use?

In general, the ability to define a patient’s condition more precisely should allow better definition of medical necessity, and consequently coverage, for tests and procedures. ICD-10 codes include many more signs, symptoms, conditions, and situations than ICD-9, and should allow payers to be more specific in what they will pay for and what they will not.

Charles Root, PhD, is CEO of CodeMap in Schaumberg, Illinois, a company that helps healthcare professionals to navigate the rules and regulations governing the federal Medicare program. +Email: charlesroot@codemap.com