The Latest Changes to ICD-10 Codes and How They Affect Billing

This comprehensive guide covers:

• Background on ICD-10 coding
• Understanding the ICD-10 update process
• Overview of 2022 ICD-10 code changes
• Steps to prepare for new ICD-10 codes
• Claim submission and reimbursement impacts
• How coding updates affect clinical documentation
• Role of coder training in ICD-10 optimization
• Leveraging technology to ease ICD-10 code updates

Ensuring your practice and medical billing teams are equipped with the latest codes, guidelines and training resources helps minimize disruptions and claim issues.

Here are key aspects of ICD-10 codes:

• ICD-10 codes cover diagnosis coding for injuries, diseases, symptoms along with external causes. Procedures are coded separately under HCPCS.
• They provide a standardized way to document medical diagnosis details across healthcare providers globally.
• ICD-10 codes used for medical billing in the US differ slightly from WHO’s base ICD-10. The CDC’s National Center for Health Statistics publishes the US’ ICD-10 Clinical Modification (CM) and Procedure Coding System (PCS).
• ICD-10 codes are alphanumeric with up to 7 characters compared to ICD-9’s 3-5 digit codes. This expands the number of possible codes to 68,000 codes for greater specificity.
• Higher ICD-10 code granularity improves clinical data analysis for research and public health.

Accurate ICD-10 coding is essential because diagnosis codes directly impact medical billing processes and revenue:

• Codes determine payer reimbursement rates and coverage eligibility.
• Incorrect or ambiguous diagnosis codes lead to claim denials decreasing collections.
• Specificity of codes impacts risk adjustment calculations by payers.

With ICD-10 optimizing coder productivity and claim reimbursement, staying updated is critical.

Given how integral ICD-10 codes are to medical billing operations, it is vital to understand the mechanism behind annual updates:

• ICD-10 updates happen annually on October 1st in the US. Any new codes are effective starting October 1st.
• Proposed code changes are reviewed by the CDC’s Cooperating Parties – American Hospital Association, American Health Information Management Association, CMS, National Center for Health Statistics and others.
• Final code modifications are approved by the Cooperating Parties by April. CDC publishes updated code sets by June.
• For 2022, new codes were published June 17, 2021 as part of the Fiscal Year 2022 ICD-10-CM update.
• Code changes include new diagnosis codes, deletions, revisions to code titles or instructions. New codes typically reflect emerging diagnoses, diseases and precision medicine.
• Code updates are incorporated into encoder software and tester files for payers and practices to prepare.
• CMS also updates its ICD-10 mappings to DRGs, MS-DRGs and APCs based on code changes which impact IPPS reimbursement.

Understanding this structured process helps practices and medical billers brace for upcoming changes.

For Fiscal Year 2022 starting October 1, 2021, ICD-10 modifications focused on greater inclusion, specificity and data collection:

• 284 new ICD-10 codes were added. 79 codes were deleted and 14 codes revised.
• New codes cover emerging conditions like Multisystem Inflammatory Syndrome in Children (MIS-C), vaping-related disorders, COVID-19 vaccines and more.
• Codes updated for social determinants like food insecurity, transportation barriers etc. to enable better data collection.
• Expanded injury codes for details like slips, trips and falls in healthcare facilities.
• New musculoskeletal codes for right vs left body parts offers greater specificity for accurate billing.
• Added obstetric codes provide specificity details around preterm labor and placental conditions.
• New codes to identify type of encounter like telehealth, in-person etc. allow tracking utilization.
• Substance abuse codes updated with new recreational drugs and further details.
• Revised diabetes codes to identify insulin use and associated complications.

Staying updated on code changes allows medical billers to avoid rejected claims due to invalid diagnosis codes starting October 1st.

While code changes may seem minor compared to the massive ICD-10 transition in 2015, proactive preparation for the annual update is essential:

• Review new and revised codes early – Analyze impact on documentation needs, coding rules and reimbursement. Update policies accordingly.
• Update encoder software – Ensure coding software and practice management systems contain the latest codes for billing teams.
• Assess payer policies – Confirm coverage and reimbursement rates for new codes with your largest payers.
• Train coders – Conduct training workshops on new coding guidelines well before October 1st cutover. Assess knowledge gaps.
• Develop cheat sheets – Handy quick-reference guides on new codes helps coders adapt faster. Include examples, definitions, rules.
• Update templates – Revise EHR templates to integrate new codes into clinical documentation workflows.
• Audit previously coded claims – Exclude expired codes from October claims. Audit previous claims for now invalid codes.
• Set interim status rules – Define policies on use of new codes for dates of service before October 1st cod eupdate.
• Communicate changes – Update all staff, especially front desk, on new codes to ensure accurate documentation capture.

With robust preparation, your coders will have the knowledge and tools needed to seamlessly apply updated codes starting October 1st.

Claims Edits and Denials

• Using deleted or invalid codes on claims for dates of service on or after October 1st will lead to rejection.
• For new codes, payers update claims editing software to recognize valid codes starting October 1st.
• Claims for new codes submitted before the update effective date will fail payer edits and deny.

Reimbursement Rates

• New codes require reimbursement fees to be established with payers initially. Rates often start low but increase over time as utilization grows.
• Code changes that increase specificity may alter DRG assignment and IPPS facility reimbursement for hospitals.
• More specific codes allow clinical nuances to be captured which can improve reimbursement over time.

Claim Scrubbing

• Scrubber software used to catch billing errors pre-submission must be updated with new codes to prevent false rejections.
• For deleted codes, scrubber rules should flag use on current claims for review vs auto-rejection.

Billing and Coding Workflows

• Integrating new codes into coding workflows, charge description master, fee schedules, claims forms etc. is critical to minimize disruptions.

Keeping billing systems, claim scrubbers and staff in sync with the latest codes is imperative to maximizing reimbursement and avoiding denials every October.

ICD-10 coding does not happen in isolation but is tied closely to clinical documentation processes and workflows:

• New or revised ICD-10 codes may require updating clinical documentation templates and forms used by physicians to capture details like laterality, severity, episode of care etc.
• Training clinicians on any documentation changes needed to support new coding requirements is essential to drive capture during patient visits.
• For new codes, establish internal coding guidelines and examples to ensure coders apply codes accurately and consistently.
• Perform audits to ensure clinicians are capturing adequate documentation details to assign newer granular ICD-10 codes.
• Documentation and coding workflows may need realignment to avoid redundancy or gaps between clinician and coder steps.
• CDI specialists play a crucial role in both clinical documentation improvement and training coders on new codes.

Clinical documentation and coding are tightly intertwined, so engaging with clinicians is vital for successful ICD-10 updates.

Thorough medical coder training and education on changing ICD-10 code sets, guidelines, and rules is foundational for accurate coding

Consider the following factors:

• Coders must understand all new and revised codes – incorrect or outdated codes lead to underpayments or claim denials.
• Official coding advice from CDC, AHA and AHIMA helps standardize local coding decisions for consistency.
• Examples allow coders to understand correct application of new codes for different clinical scenarios.
• Clarifying documentation requirements avoids coding based on insufficient physician notes.
• Training aids smooth adoption of new codes into existing workflows starting October 1st.
• Assessing coder knowledge gaps helps target additional training to boost competency.
• Periodic refresher courses prevent knowledge decay or reliance on outdated policies.
• Certifications ensure coders have met accredited training standards – like AHIMA’s CCS credential.

Continuous training investment equips coders with the skills and confidence to quickly adapt to ongoing ICD-10 changes.

Sophisticated software tools can help streamline many aspects of ICD-10 updates:

• Encoder software automatically updates to the latest codes for use in billing workflows.
• Computer-assisted coding optimizes code search and assignment based on documentation.
• Natural language processing extracts diagnosis details from unstructured clinical notes to suggest codes.
• Electronic documentation tools prompt physicians for details needed to support specific codes during visits.
• Claims scrubbing software automatically detects invalid diagnosis codes prior to submission.
• Analytics help track utilization of new codes and resulting reimbursement rates over time.
• Change management tools identify documentation gaps between clinicians and coders.

Technology removes much of the complexity associated with ICD-10 optimization – enabling billing teams to adapt faster and maximize opportunities from the latest codes.