As of October 1st, the coding standard for diagnosis coding has changed in the United States. It’s gone from what used to be called ICD-9 to ICD-10. Hospitals and physicians across the country have been scrambling to get their coders trained for the new system, even though it’s been around since 1995, because most insurance companies pay based on a combination of procedure and diagnosis codes, and the switch means going from around 16,000 coding possibilities to around 111,000; that’s a major change!

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If you’re a patient and hearing this for the first time, it might mean that you either don’t care or you’re unsure of how it could affect you in at least the short term. To get a better understanding of this, there are a few things you should know.

First, diagnosis coding is one of the hardest things in the world to do. Get it wrong and it could cost a lot of money in either lower reimbursements from insurance companies or fines for what’s known as “upcoding”, which is when you say the severity of a patient’s malady is worse than it really is and get paid more money for it.

Two, codes have gone from 5 digits to possibly 7, and in some cases one of those digits might need to be skipped. For instance, the general diagnosis code for diabetes was 250.00. Then there were two other numbers, which went into the 5th digit being either 0, 1 or 2.

Now, for the most part it’s either E11.9 (Type 2 diabetes mellitus w/o complications) or E13.9 (Other specified diabetes mellitus w/o complication) to begin with. After that, there are nearly 60 other ways these can be coded to be more specific in the type of diabetes and which area of the body it’s affecting.

Notice I said “most part”? That’s because there are 2 more categories for diabetes reporting that, luckily, won’t be reported as often. Those are E08, Diabetes due to underlying condition, and E09, Drug or chemical induced diabetes mellitus.

Overall, it’s not important for most people to know that but coders need to know these things because a couple of the codes above, along with their additions, could alter the amount of payment that comes in from insurance companies.

Second, although it’s always been important for physicians and nursing staff to put down everything in the medical records and as accurately as possible, it’s even more important now. Without all the extra information, coding will be sketchy and reimbursement could be affected greatly. Physicians offices have been notorious for not fully completing medical records, having staff assume things that, upon audits, can’t be proven. Even things like not documenting time properly could cost thousands of dollars a year.

Third, even though there’s a new standard, it doesn’t cover all insurances across the board. Right now, states that have compensation plans are exempt, as are agreements with employers to provide contracted services. The same goes for no fault in many states. This means coders will have to remember two different coding standards; how hospitals and physicians offices will handle this type of thing is unknown.

There are a lot more things that could be brought up but that should be enough to show how complicated things could possibly get. What’s important is answering the question of how it could affect patients.

There are really only 3 ways this can affect patients. They are:

1) If accounts are miscoded, it’s possible that insurance companies could deny claims, which would make patients responsible for them. Actually, this type of thing has always happened, so patients should always be ready to call their provider to ask for clarification as it’s usually more of a clerical error than anything else.

2) It could take longer for claims to be resolved, which means if patients owed a balance afterwards it could be longer before they know about it. Once again, this is something that happens now, but with the complexity of the new coding system it could even take longer to get resolution.

3) It becomes more important for patients to disclose more information to their physicians to make sure things are coded properly. Going back to the diabetes example, physicians might start asking more things about how one’s body feels and what’s going on so they can include it in their coding. Formerly, a lot of questions concerned feet, tingling of body parts and possible heart issues. Now you might be asked about your teeth, your eyes, wounds on your body, and a host of other things so they can code properly. If it’s this way with diabetes, it’s going to be this way for everything else.

Overall though, most patients won’t notice anything different and that’s a good thing. If you do, make sure to call your health care provider and ask a lot of questions to get your claim taken care of.
 

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