How to Recognize an ICD-9 Code from the Other Codes

From the problems some people are having with the NCTracks ICD-10 Crosswalk to the questions we have received in the NCTracks ICD-10 inbox, it is clear that code recognition is a challenge for some providers. This article provides key information to help providers understand the distinction.

But before we get into the details, it is said that a picture is worth a thousand words, so here is a screen shot from the NCTracks Provider Portal, illustrating the difference between an ICD code and a CPT code, in terms of where they go on a professional claim.

Background Information about Coding

There are several different types of codes used in healthcare today. The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide standardization for describing specific items and services provided in the delivery of health care. HCPCS includes two levels of codes:

· Level I consists of the American Medical Association’s (AMA) Current Procedural Terminology (CPT) and is numeric. CPT coding identifies the medical, surgical and diagnostic services rendered on the claim. New editions are released each October.

· Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services not covered by CPT codes Level I.

HCPCS/CPT codes are the procedure codes used by most non-inpatient providers when billing NCTracks. Other than the normal annual update, HCPCS/CPT codes are NOT changing.

The International Classification of Diseases is maintained by the World Health Organization (WHO.) The International Classification of Diseases, Clinical Modification (ICD-9-CM) is an adaption of the ICD code set created by the U.S. National Center for Health Statistics (NCHS) and used in assigning diagnostic and procedure codes in the United States. NCHS and the Centers for Medicare and Medicaid Services (CMS) are responsible for overseeing all changes and modifications to ICD-9-CM, which is updated annually on October 1. This year, that update is the transition to ICD-10 codes.

The ICD-9-CM code set includes volumes 1 and 2 (diagnosis codes) and volume 3 (procedure codes.) ICD-9-CM diagnosis codes are used by most providers, except dentists (unless the patient is dually eligible) and will be replaced by ICD-10-CM.

ICD-9-CM procedure codes are only used in inpatient settings. ICD-10-Procedure Coding System (PCS) will replace volume 3 of the ICD-9-CM for inpatient procedure codes.

In review, the code sets currently used are:

· CPT – procedure codes (physicians, radiology, labs)

· HCPCS – procedure codes (drugs, supplies, prosthetics, vision)

· ICD-9-CM volumes 1 and 2/ICD-10-CM – diagnosis codes

· ICD-9-CM volume 3/ICD-10-PCS – procedure codes used in hospitals only

Know the difference between a diagnosis code and a CPT code

An ICD-9-CM code (which will become an ICD-10-CM code this year on October 1) is used to describe a symptom, condition, or disease that is being treated, also known as the diagnosis code.

For Example: A patient was seen in the physician’s office today with chest congestion and a cough. After examination the physician diagnosed the patient with an acute upper respiratory infection. The ICD-9-CM diagnosis code for today’s patient visit would be represented by the ICD-9-CM code digits 465.9, which represent the acute URI.

Note: In this case, the chest congestion and the cough are symptoms that are part of the diagnosis of acute upper respiratory infection and are not coded separately, unless warranted.

A CPT code is used to describe the evaluation and management (E/M) code (meaning the physician time, intensity of service, and complexity of the examination performed on a patient at each visit, when applicable.) It can also be used to describe any treatment or diagnostic services (lab tests, radiology tests, immunizations, and so forth) provided to the patient, also known as the procedure code. 

So let’s go back to our example of the patient that was seen today for the diagnosis of upper respiratory infection. In order to submit a claim to be paid by the patient’s insurance carrier, such as NCTracks, the physician will submit a CPT code to describe the level of the evaluation and management that was performed on the patient. For example, let’s say for today the physician selected the E/M CPT code of 99212 (meaning the patient is an established patient and the physician billed a lower level office visit) to describe the time, intensity, and complexity of the examination performed on the patient. The diagnosis code (ICD-9-CM code) 465.9 will be attached to the CPT code 99212 on the claim to tell the insurance carrier the reason for the patient’s visit today at the physician office.

Just remember, the physician must attach ICD-9 diagnosis code(s) - the reason for the visit - along with the CPT procedure code being submitted on the claim.

So come October 1, when ICD-10-CM codes become effective, instead of using an ICD-9-CM diagnosis code(s) on the claim, providers will start using ICD-10-CM diagnosis codes in their place. Everything else will remain the same as it is now for reporting CPT procedure codes.

Additional Resources

For additional information about the various code sets and ICD-10, providers may wish to consult these resources from the Medical Group Managers Association (MGMA) and the AMA:

http://www.mgma.com/icd-10-5010-implementation

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

The Centers for Medicare and Medicaid Services also have a valuable education tool for providers interested in better understanding the different code sets at

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD9-10CM-ICD10PCS-CPT-HCPCS-Code-Sets-Educational-Tool-ICN900943.pdf

Final Word

Correct coding is the responsibility of the provider. Later this summer, NCTracks will offer training on how to submit ICD-10 codes, how they are used in the system, and the changes made to portal screens, reports, etc., but it will not cover basic coding.

For more coding education or training, check with your professional organizations and advocacy groups. Some community colleges are also offering courses on ICD-10 coding. The opportunities to learn more about ICD-10 are numerous and providers are encouraged to take advantage of them.

 

 

Thanks to Lee Ford, co-chair of the NCHICA ICD-10 Task Force, Tammy Norville, DHHS Office of Rural Health and Community Care, and Dr. Nancy Henley, Chief Medical Officer of the NC Division of Medical Assistance, for their insight and contributions to this article.