July 19, 2024
Close this search box.
Close this search box.
July 19, 2024
Close this search box.

Linking Northern and Central NJ, Bronx, Manhattan, Westchester and CT

Clean Bill of Health: Medical Codes

Assuming Congress doesn’t intervene, on October 1st one of the essential mechanisms with which medical providers code their insurance claims will undergo a radical change.

My apologies in advance for selecting a rather dry topic, but I will do my very best to make it interesting, and as healthcare consumers it is important that you know what happens with your medical bills.

Managed by the World Health Organization, the International Classification of Diseases (known by its acronym ICD) is used by healthcare organizations and governments around the world for, in the WHO’s own words, “analysis of the general health situation of population groups.” Each country is free to tweak the version of the ICD codes it uses, but by and large they are uniform. Here in the United States, ICD codes are used by providers to indicate the patient’s diagnoses on claim forms, a unique utilization.

On October 1, providers in the U.S. are mandated to switch from the “old” version, ICD-9, to the “new” version, ICD-10. (We covered diagnosis codes in the introductory issue of this column.) This shift is expected to cause major headaches for providers, medical institutions, health insurance carriers and, in consequence, consumers. The reasons for the expected headaches are myriad, and include the following: (a) the structure of the ICD-9 and ICD-10 codes are radically different, (b) there is not a one-to-one relationship between the two code sets, as it is a ground-up overhaul, (c) although the mechanisms for processing the new codes have supposedly been tested by all the players, real-world use is often unpredictable, and (d) getting all of this right is required in order to have medical claims paid properly and in a timely fashion.

If there is failure at any point along the way, the whole payment system for medicine grinds to a halt.

Needless to say, the ICD-9-to-10 shift has been a great cause of anxiety in the American healthcare ecosystem. In fact, this implementation has already been pushed off a few times, and still many players are not prepared for the change. Physicians have new code sets to learn, which will replace existing codes that they have been used to for many years (the “old” code set went into use in 1979, and has only one-fifth the number of codes in the “new” code set). Insurance carriers must update policies and rules for the new coding system. Purveyors of electronic systems must update their software, sometimes requiring rewriting of major components from scratch. And the list goes on and on. Physician anxiety about this change has recently led the American Medical Association to circulate a petition asking Congress to intervene and delay implementation to 2017 or later.

So what does all this mean for you?

Assuming the shift to ICD-10 goes forward, you should be prepared for the following:

• There may be lack of clarity (from providers, hospitals and insurance carriers) regarding how the change affects your coverage for certain services.

• There may be a time lag between your receiving medical services and the processing of the claims for those services by your insurance carrier. There may also be sudden resolution of multiple claims, resulting in bills for many dates of service arriving all at once.

• There may be (substantial) errors in the processing of those claims, which can result in erroneous bills to you (which you should not ignore, even if they are errors).

• Your provider’s billing departments may be backlogged dealing with these issues, and the carriers may be backlogged in responding to the billing departments’ requests, resulting in resolution delays for you.

Recognizing that the system is undergoing substantial change, and preparing to be patient about it, will go a long way in helping keep you calm should these problems transpire. All the players are doing their best to be ready and avoid problems. After all, it is in everyone’s best interest to get all the parts of the system working properly and in sync, and the carriers and providers are just as eager as the patients to avoid major problems.

If you do get unexpected bills as a result of this change, be sure to investigate them without delay, but bear in mind that this will be a major shift for the industry, and you will not be the only one affected.

That is, unless Congress pushes the whole thing off again.

Yossi Faber earned his MBA in Healthcare magna cum laude from the joint Mount Sinai School of Medicine—Zicklin School of Business program at CUNY Baruch. He is a member of two healthcare industry-focused networks of expert professionals, and is an invited lecturer at major medical centers and state medical societies. He founded and manages Clean Bill of Health (www.cleanbillofhealth.com), which provides both medical billing services to physicians as well as advocacy services for patients to review and help reduce the burden of their medical bills. Yossi lives in NJ with his wife and children.

By Yossi Faber

Leave a Comment

Most Popular Articles