The Perfect Storm

Following an unanticipated one-year postponement of ICD-10, the tenth revision of the International Statistical Classification of Diseases and Related Health Problems, the transition from ICD-9 to ICD-10 is now scheduled to take place in the U.S. on October 1, 2015. Even though this new coding process will offer many benefits in data collection that should translate to better patient care, this conversion will create significant complexities and liabilities for providers and hospitals.

The most significant change for clinicians is that the ICD-10 system requires greater specificity in medical record documentation. This is evidenced where a single ICD-9 code could potentially translate into numerous ICD-10 codes, requiring the necessary documentation. Even though General Equivalency Mapping (GEMS) is available, there are significant limitations in that less than 10% of all ICD-9 codes will map accurately, 1:1, with ICD-10. It is likely that both systems will remain in use during the transition period creating significant potential for double or duplicate billing.

Physicians continue to struggle with accurately coding CPT Evaluation and Management (E&M) codes. At times, this behavior is intentional and a means to increase reimbursement. Examples of this include upcoding, misrepresenting a diagnosis, and even billing for services not performed. While it will be some time before we see billing fraud involving ICD-10, this perfect storm sits on the horizon, ever present.