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How will ICD 10 Challenges Affect Dermatology Practices?

December 18, 2014

ICD 10 DermatologyAs all private medical practitioners are keenly aware, the October 2015 conversion date for ICD-10 code conversion will soon be here. Dermatologists will be as impacted as their colleagues in other specialties, but have some unique concerns, given the specificity the ICD-10 codes lend to diagnosis, treatment, billing and reimbursement of often similar conditions. With the ICD-9 codes, one diagnosis code was acceptable for billing a band of conditions and treatments. ICD-10 codes require a greater level of granularity than many practices have previously had to provide. The ICD-10-CM, derived from the World Health Organization’s Global Health Data Repository, has twenty-two chapters, with over 68,000 codes.

Simplified Doesn’t Mean Simpler

The greater functionality and granularity of ICD-10 can be seen in the coding possibilities for Psoriasis. As an ICD-9 diagnosis it has only one code, 696.1. Under ICD-10, though, it’s possible— and required — to differentiate it. Codes in Chapter 12, “Diseases of the Skin and Subcutaneous Tissue,” begin with “L.” Some candidate codes are “Pustular Psoriasis on hands and feet” – L40.3 and “Guttate Psoriasis” – L40.4.

Codes have necessarily grown in length. An ICD-10-CM code can be up to 7 characters, though dermatological codes typically won’t range beyond four to six characters. The longest codes and code occurrences in dermatology will usually be those reflecting laterality, the need for multiple codes and diagnostic history:

Laterality – Especially in neoplasms, laterality (occurrence on right or left) may need to be indicated. Code C44.122 is “squamous cell carcinoma of the right eyelid,” with the 6th character “2” representing right. Were it the right eyelid, it would be a “9”.

Multiple Codes – Causation may need to be cited. “Abscesses, furuncles, and carbuncles” requires a causative bacteria code.

Diagnostic History – ICD-09 had many “shared” diagnostic codes”— Melasma and Solar Lentiginesshare diagnostic code 709.09d. ICD-10 logically assigns each its own code, both of which must be cited: (L81.1 and L81.4, respectively).

Any ICD-10 coding error can result in nonpayment of a claim. And obviously there’s lot of room for error, especially when ICD-10 goes live. CMS warns that post-10/14 implementation, claims denial rates may rise by 100 to 200 percent and accounts receivable days could increase from between 20 to 40 percent. Practices’ cash flow and revenue could be negatively impacted for up to two years after ICD-10 implementation.

Though ICD-10 conversion and accurate billing presents all medical practitioners with some stiff challenges, it also offers rewards through improve diagnostic specificity, patient care and a hugely expanded pool of data that can inform epidemiology and treatment worldwide. The complexity of ICD-9 to ICD-10 conversion is less daunting if seen as the modernization of our diagnostic lexicography, best managed through a careful but timely selection of the right conversion tools. The best of these are part of state-of-the-art coding systems integrated within a practice’s electronic health records (EHR) suite.

Meeting the ICD-10 Challenge

October 2015 is fast approaching. Some practices that haven’t reliably automated the full range of ICD-10 processing within their EHRs are resorting to such risky billing practices as cloning or over documentation. Cloning’s a manual cut and paste process of transferring medical billing codes from one electronic document to another. It’s prone to transcription errors that can delay payments, create inaccurate patient information and trigger CMS audit alerts. Over documentation is fostered when a coder use EHR templates that spawn extensive and inaccurate ICD-10 data, generating billings for more services than occurred. It, too, can trigger audit alerts.

Cross-walk or NLP?

Most practices are approaching the ICD-10 conversion through either cross-walk or natural language processing (NLP) systems. These are distinctly different solutions requiring a thoughtful cost-benefit analysis before committing to one or the other.


Cross-walk is an ICD-09 to ICD-10 solution that maps old codes to new through a conversion process within a practice’s current claims billing system. Cross-walk’s a labor-intense hybrid, producing billings that are often inaccurate and populating downstream medical management and contract systems with incompatible data. It’s a stop-gap measure at best, as all EHR systems must be fully ICD-10 compliant by 2015. Which crosswalk systems are not.

Natural Language Processing

ICD-10 conversions using natural language (NLP), computer-aided coding systems have proven very reliable over the long-term. In the hands of skilled medical billing coders serving as editors, an NLP provides a sophisticated, self-learning environment with the lowest error conversion rate. Of the two different possibilities, an NLP typically requires the most upfront investment. But with training and support from a well-regarded firm, NLPs more than pay for themselves over time through increased claims approvals, lower labor costs and improved records accuracy.

Time to ICD-10-CM conversion is growing short. Dermatologists, as with other practitioners, need to weigh their ICD-10 conversion options now and begin implementing solutions that will best serve their future and their patients.


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