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ICD10The ICD-10-CM codes and instructions are published for free by the government and are also available in a myriad of print and electronic publications, but proper understanding of ICD-10 coding requires a much deeper set of resources than just “the code book.”

It is important for providers and payers to understand claims processing edits, crosswalks to payment rules such as Hierarchical Condition Category (HCC) and Medical Severity Diagnosis Related Group (MS-DRGs), quality reporting, coverage rules, and much more. Let us examine these diagnosis-related data sets, their purposes, and their sources, and denote which have been published with ICD-10-CM codes.

ICD-10-CM Codes and Instructions: “The Code Book”

The Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS), provide the complete set of content that makes up the ICD-10-CM code set. (These resources have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.) All content is available for free on the Internet.

Sections that make up the basic coding information include:

  • Code Descriptions in Tabular Order
  • Official Guidelines for Coding and Reporting
  • Tabular List of Diseases and Injuries
  • Index of Diseases and Injuries
  • Index of External Causes of Injuries
  • Table of Drugs and Chemicals
  • Classifications of Drugs
  • Table of Neoplasms

Publication Information:

The Centers for Disease Control (CDC) and CMS have published the complete ICD-10-CM information for 2013. Most content is in PDF format and some is available as XML files. The 2014 information is pending.

Medicare Code Edits and Attributes for Claims Processing

Diagnosis codes on Medicare claims are subject to a number of different checking rules or “edits.” These rules check for things like whether or not a code is valid or “reportable,” whether the age and gender of the patient makes sense for a given code, and more. There are two manuals that CMS publishes that detail diagnosis code edits: the Integrated Outpatient Code Editor (IOCE) for outpatient and physician claims, and the Medicare Code Editor (MCE) for inpatient claims.

Key lists of code attributes and edits include:

  • Age Edits:
    • Adult diagnoses
    • Newborn diagnoses
    • Pediatric diagnoses
    • Maternity diagnoses
  • Gender Edits:
    • Diagnoses for females only
    • Diagnoses for males only
  • CC/MCC Edits:
    • CC List” – Diagnoses Defined as Complications or Comorbidities
    • “MCC List” – Diagnoses Defined as Major Complications or
    • Complications and Comorbidities Exclusions list
  • Hospital Acquired Conditions/Present On Admission Edits
    • Hospital Acquired Conditions List
    • Present on Admission Exempt Code List

Publication Information

The edits are subject to the public rule-making process. CMS has published 2013 draft versions of the IOCE and MCE definitions manuals in PDF and TXT versions, but has not made these critical lists available in an easy-to-use data format. The 2014 information is pending.

Medicare Quality Reporting

The Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The reporting process includes a list of specific quality measures mapped to diagnosis and procedure codes.

Publication Information

CMS publishes quality information in both PDF and excel format. CMS has included 2013 ICD-10-CM codes in the PQRS “Single Source Code Master” XLS file and denoted them as “for reference only,” since they cannot be currently used for quality reporting. Codes for 2014 are pending.

Medicare Coverage and Medical Necessity

Medicare and the Medicare Administrative Contractors (MACs) publish narrative “Coverage Determinations” that detail coverage specifications (including diagnoses) for procedures and services.

Publication Information

The Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) include a coding section that is generally used to specifically list ICD-9-CM diagnosis codes that support medical necessity. We should expect to see draft LCDs in 2014 with this information translated to ICD-10-CM.

Historically, CMS publishes National Coverage Determinations (NCDs) with a discussion of the indications and limitations of coverage, but do not translate that to specific diagnosis or procedure codes. Recently, CMS has begun issuing special transmittals with attachments that list the ICD-10 codes that would apply to a medical necessity edit related to specific NCDs. It points out that this is an exercise, and it is unclear whether it intends to continue to publish this information so transparently. An interesting part of this exercise is the translation of the coding rules for both Medicare Part A and Part B, which includes an implied ICD-9-PCS to CPT® crosswalk for services that are addressed by a NCD.

Example: R1199OTN [CR 8197] dated March 15, 2013, International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs).

Medicare Inpatient Prospective Payment System

CMS uses a Medical Severity Diagnostic Related Group (MS-DRG) methodology to determine payment for inpatient stays. This system relies on a grouping methodology where the patient diagnoses and the procedures performed during the stay are “grouped” to MS-DRG.

Publication Information

CMS has published a pilot 2013 (version 30) ICD-10 MS-DRG Definitions Manual, which explains the diagnoses and procedures assigned to a given MS-DRG, and also a software program called the “Grouper and Medicare Code Editor,” which must be purchased separately. A manual for 2014 is pending.

Medicare CMS-HCC Risk Adjustment

CMS uses a risk adjustment payment system, called the Hierarchical Condition Category (HCC) payment model, to pay Medicare Advantage (MA) and Prescription Drug Plans (PDPs) accurately and fairly by adjusting payment for enrollees based on demographics and health status. The payment model relies on clinical coding (ICD-9-CM codes) gathered by providers and submitted by the health plans to CMS. HCCs lump 3,100 diagnoses from the ICD-9 system into about 70 diagnostic groups.

Publication Information

ICD-10-CM to HCC grouping is not yet available.

Regulations and Regulatory Guidance

Additional information will be published by HHS, CMS, CDC, other agencies, state governments, and state Medicaid agencies. Providers should monitor and track this incoming information to incorporate into policies and procedures.

Publication Information

  • Federal Register Proposed and Final Rules

Watch for announcements about ICD-10 as it relates to the yearly prospective payment system updates, quality reporting requirements, code edits, and other rules that are established via the rule-making process.

  • Medicare Internet Only Manuals (Pub 100s)




CMS has already begun revising sections that include specific ICD-9 codes to provide the ICD-10 translation. They tend to put the term (ICD-10) in the title. As an example, see CR 7806, which revised Pub 100-02, -03 and -04 sections related to Extracorporeal Photopheresis.

  • MLN matters, Special Edition, Fact Sheets, and educational materials have and will continue to be published by CMS. Some of these are simply incorporated into existing documents; others are specifically called out and listed on the CMS ICD-10 page.
  • CMS General Equivalence Mapping (GEM) files that provide mapping between ICD-9-CM and ICD-10-CM are available on the CMS ICD-10 web page.
  • The Center for Disease Control (CDC) publishes outreach, education, and advocacy materials; data repository information; and shared ICD-10 training resources with other HHS agencies.
  • Health Resources and Services Administration (HRSA) produces webinars and newsletters to HRSA grantees related to ICD-10 adoption.
  • National Institute of Health (NIH) Surveillance Epidemiology and End Results (SEER) program creates mappings for key ICD-10 impact areas including registries and research databases.
  • Indian Health Services (HIS) Steering Committee has produced resources for I.H.S. institutions including “Have No Fear of ICD-10” boot camp, clinical rounds, and a full-blown communications plan.
  • The Medicare Administrative Contractors (MACs) have started to produce ICD-10 guidance in various locations on their websites.

Each of these data sets, currently published in relation to ICD-9-CM codes, has or will need to be republished with ICD-10-CM codes.

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding and reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

© 2013 CCH, Incorporated

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