Altruis Blog

What is ICD-10 and how do ICD-10 codes work?

Jun 19, 2019 11:45:00 AM / by Chris Caspar, CEO

What is ICD-10? ICD-10 codes are a powerful tool for community clinics to document and address social determinants of health--but they’re drastically underused. Perhaps because they aren’t fully understood. We’re going to start with the basics... You probably know most of this, but your team may not, so you may want to share this post with them. Then we’ll dive into what’s happening vis-à-vis ICD-10 and social determinants of health.

ICD-10 basics

ICD-10 codes are alphanumeric codes used by clinicians, insurers, public health agencies and others to represent diagnoses. Every health problem--injury, illness, etc.-- has an ICD-10 code. (As we’ll discuss shortly, we do mean every.)

Developed and published by the World Health Organization, ICD--the International Classification of Diseases--provides what WHO describes as a language-independent framework for disease classification. It is the international standard diagnostic classification for all general epidemiological purposes, and it’s used to collect national mortality and morbidity statistics by WHO member countries. It’s an important global public health tool.

Need to know more?

And one more thing: WHO regularly updates the ICD; ICD-11 was unveiled at the World Health Assembly in May 2019. It will take effect Jan. 1, 2022. And yes: Burnout from work is now officially a syndrome.

How ICD-10 works in America…

Here in the U.S., when most people talk about ICD-10, they are referring to ICD-10CM. ICD-10-CM codes are more detailed than ICD-10 codes. (CM stands for “clinical modification.”) Another set, ICD-10, is used only in the inpatient setting. All HIPAA-covered entities must adhere to ICD-10-CM or ICD-10-PCS.

ICD-10-CM has been revised frequently since 2003. The 2019 update contains 71,932 codes. Who decides? The Cooperating Parties for the ICD-10-CM decide: the American Hospital Association, the American Health Information Management Association, CMS and the National Center for Health Statistics.

Why it matters

Why is it important for community clinics?

ICD-10-CM provides a way to more easily identify patients in need of disease management and to better tailor those programs, according to a RAND study.

More broadly, that data can help you better evaluate and improve the quality of patient care. For example, as the Journal of AHIMA points out,  the data “could be used in more meaningful ways to better understand complications, design clinically robust algorithms, and track care outcomes.”

Current screening tools for social determinants of health (SDOH) are aligned with ICD-10-CM codes. Among them: The National Association of Community Health Centers’ PRAPARE (the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences).

The role of the codes for safety net providers will soon become more important.

Capturing social determinants

ICD-10-CM includes a set of codes--Z codes--that can capture information related to social determinants. Each Z code has sub-codes to allow for greater specificity.

These codes aren’t new, but they are vastly underused. This, according to the Institute for Medicaid Innovation, “limits opportunities to reliably identify and respond to social needs.”

The broad categories of the current Z codes are as follows:

  • Z55 – Problems related to education and literacy
  • Z56 – Problems related to employment and unemployment
  • Z57 – Occupational exposure to risk factors
  • Z58 – Problems related to physical environment (excluding occupational exposure)
  • Z59 – Problems related to housing and economic circumstances
  • Z60 – Problems related to social environment
  • Z62 – Problems related to upbringing
  • Z63 – Other problems related to primary support group, including family circumstances
  • Z64 – Problems related to certain psychosocial circumstances
  • Z65 – Problems related to other psychosocial circumstances

One reason they aren’t being used is the misconception that any documentation for the codes must come from the physician (or PA/NP). But that hasn’t been the case for more than a year since early 2018. That’s when guidance from the American Hospital Association stated that providers can assign social determinant codes based on documentation from any member of the care team, including social workers and case managers.

Another reason could be that these codes are simply inadequate: Codes don’t exist for many social determinants. That may change soon: The list of Z codes is likely to get longer. The American Medical Association and UnitedHealthcare are promoting creation of 23 new ICD-10 codes related to social determinants.

Among the social factors that the new codes would capture:

  • Access to nutritious food
  • Adequate and safe housing
  • Available transportation
  • Financial ability to pay for medications
  • Financial ability to pay for utilities
  • Caregiver needs

Association of American Medical Colleges (AAMC) voiced its support, articulating the value of such a move:

Accounting for SDOH in ways that isolate inequitable differences in measured quality can raise awareness and enable the development of interventions that reduce healthcare inequities and improve quality and efficiency. It can also improve accuracy in reporting, estimating costs in capitation models, and compensating providers fairly. The AAMC believes that the proposed ICD-10-CM codes are an opportunity for providers to voluntarily begin to collect more granular data that can improve outcomes by identifying specific barriers to care, and for appropriate risk adjustment to fully capture SDOH factors.

If approved, the new codes take effect Oct. 1, 2020.

So, between now and then, you may want to brush up on how ICD-10-CM works.

The nitty gritty: ICD-10 code structure

If you don’t work directly with the codes, you may not understand what each character means.

  • The first character must be an alpha character.
  • The second and third must be numeric.
  • Four through seven can be a combination.
  • The first three characters describe the ailment or injury.
  • The fourth through sixth characters detail the cause, anatomical location and severity.
  • In some codes, a seventh character is an extension digit, used to classify an initial, subsequent or sequela (late effect) treatment encounter.
  • Some codes include "X" as a placeholder to allow for expansion.

Let’s use W2201--walking into a wall--as an example.

The parent code is W22.0 - Striking against stationary object. W2201 requires an additional character.

  • W2201A would be the initial encounter
  • W2201D would be a subsequent encounter
  • W2201S would be treatment an infection or other complication that arose from the original injury (sequala)

There’s a code for that

Walking into a wall may be uncommon, but it has nothing on other codes.

Ever feel like you’re being nibbled to death by ducks? There’s a code for that--assuming it’s not just a metaphor. As important as these codes are, they have been a source of mirth--or at least puzzlement-- for various providers, coders and anyone who stumbles across them.

  • W61.33: Pecked by a chicken
  • W61.32: Struck by chicken
  • W61.61: Bitten by duck
  • W59.22: Struck by turtle
  • R46.1: Bizarre personal appearance
  • V97.33XD: Sucked into jet engine, subsequent encounter

That adage about measuring…

If you can’t measure it, you can’t manage it. ICD-10 provides the tools to measure.

Complete and accurate ICD-10 coding plays a key role in identifying and tracking preventable complications and, to a lesser extent, social determinants. It can also improve patient outcomes and reduce costs.

More detailed records aren’t just for reimbursement--it’s a way to better understand and treat your patient population--although it may be wise to start thinking in terms of reimbursement.

As health policy changes you may need to code with an eye toward reimbursement. And it could be costing you today: Grants are based largely on visit type. Failing to code correctly could lead to lost money.

All of this is easier said than done: Coding is already overly complex, and changes--even ones designed to simplify--can increase the burden. Safety net providers need a partner that understands the nuances of ICD-10 and how to ensure everything is captured in the EHR. Altruis can help. Let us show you how in a free, no obligation 30-minute billing assessment.

Topics: "icd 10", "icd 10 codes"

Chris Caspar, CEO

Written by Chris Caspar, CEO