Skip to main content

ICD-10, ICD-10 CM and ICD-10 PCS Are Not Same

January 2, 2013

ICD-10 CMThe “ICD” in ICD-10 stands for the “International Classification of Diseases and Related Health Problems.” It is an international coding system maintained by the World Health Organization (WHO), an agency of the United Nations. WHO maintains a data base online of ICD-10, including code definitions, tutorials, and study guides. This is not the version that professional medical coders and billers need to master by October 2014.

Some countries, the United States included, adapt ICD codes to their own uses. This happened with ICD-9 and it is an essential component of ICD-10 billing. While medical codes are used statistically to track disease and treatment patterns throughout the U.S., the main use of medical code is for reimbursement purposes. Medical billers need to be prepared to deploy ICD-10-CM and ICD-10-PCS when the U.S. healthcare system makes its ICD-10 transition. The version maintained by WHO will be of no use, only the clinical modification and procedural coding system maintained by CMS.

The final version of ICD-10-CM, which is expected to contain 68,000 diagnosis codes, has not been completed. There is a current version, but like ICD-9 codes, ICD-10 will be updated annually. The 2014 version will not be finalized until shortly before the code sets are implemented.

This leads to a conundrum for the medical billing industry. Certified medical coders and medical billers have received notice that they will need to relearn a large portion of their professional knowledge. In the meantime, they need to remain proficient in the skills they already possess. The underlying principals of each coding methodology remain the same, but the composition and focus of diagnostic coding is changing dramatically, with an increased emphasis on specificity of data.

Anyone looking at the WHO version of ICD-10 will find it confusing, but the information promulgated by WHO is irrelevant to ICD-10 billing in the United States. Medical practices who submit claims to insurers need to be prepared to put ICD-10-CM, as approved by CMS, into practice on October 1, 2014.

Professional coders and billers have access to certified training opportunities through their professional associations. Medical practices can hire consultants to provide training to their staffs in ICD-10 coding protocols. Practices that contract with private billing services or EHR vendors have an excellent resource for ensuring that practice will be ready when the conversion takes place.

It is anticipated that the improved structure and specificity of ICD-10-CM/PCS will facilitate the development of increasingly sophisticated electronic coding tools that will assist in faster code selection. Because ICD-10-CM/PCS is much more specific, is more clinically accurate, and uses a more logical structure, it is much easier to use than ICD-9-CM. Most physician practices use a relatively small number of diagnosis codes that are generally related to a specific type of specialty. Practice Management vendors need to ensure that they have the enough understanding and resources required for this new and greatly expanded coding system. With the right Practice Management software in place, a practice can be assured that it will be able to submit clean and accurate healthcare claims at the time of conversion. Everyone who uses this software must be educated in the principals and methodology of the new codes in order for documentation and claims to be submitted seamlessly.

ICD-10-CM codes can consist of up to seven characters. The first three characters identify the category of the medical condition. The fourth character identifies its etiology. The fifth character identifies the body part affected, and the sixth character describes the condition’s severity. The seventh character is saved for code extensions that increase specificity. All aspects of the medical record are affected by the requirements of ICD-10 conversion, not just the claim forms.

ICD-10-PCS is a complimentary set of codes expected to number approximately 78,000 codes. ICD-10-PCS is designed to be used in the hospital setting. Outpatient medical practices need to be familiar with the concepts underlying ICD-10-PCS, but their providers and billers need to be masters of the codes and their underlying concepts contained in ICD-10-CM.


Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch