What is ICD-10 and Why are Insurance Claims Being Denied…

By Jill Buterbaugh, RN, MSN, CRNP, FNP-BC

On October 1, 2015, the World Health Organization which our government is part of, mandated that all medical diagnosis must be given a code compliant with International Classification of Disease (ICD), 10th edition.  Before October, all health care providers and insurance companies in the United States used ICD 9th edition to assign a classification code to a diagnosis.  This code tells the insurance companies what health diagnosis your medical providers are treating to justify payment for care.  It allows certain procedures and diagnostic testing to be done that are appropriate for that diagnosis.  With the change from the 9th to the 10th edition, it expanded the coding from up to a 5-digit code to up to a 7-digit code allowing medical providers to more specifically title the diagnoses.  For example, if you fell and caused a contusion to your leg, ICD 9 would have resulted in a code of 924.5 which is simply defined as a single contusion to a lower extremity.  The coding for ICD 10 makes you define if it is the right or left leg and if the medical visit for this injury was the initial office visit, subsequent office visit or a complication of the contusion.  So a code for a simple contusion to the lower extremity could result in 18

The change from ICD-9 to ICD-10 required many hours of training office staff, medical providers and insurance companies how to accurately determine the new codes.  It increased the amount of documentation required at each office visit in order to more specifically identify the medical problems.  It required updates in computer systems in offices, hospitals, and insurance companies across the country.  When procedures were done in the past, there was a list of diagnosis linked to the procedure that verified that the procedure was justified by the diagnosis code used.  The computer could identify this and payment for the procedures was initiated.  Those lists were very extensive and with the change in the coding, all the medical insurance companies had to change the diagnosis codes associated with every procedure.  It also required every insurance carrier to change their policies to reflect this update.

The rejection of claims that some patients are getting letters about generally are due to the computer systems not identifying the new codes as appropriate for the procedure done or the insurance company employees not having access to updated information.  It doesn’t mean the procedures are not going to be paid for, but it identifies where systems are lacking communication.  Often, once identified, these issues can be corrected and the claims will be paid.  If any additional information is needed from you, the patient, we will be in touch immediately.

The change in the medical billing system was monumental and although dealing with insurance companies can be very confusing and frustrating, most offices have people who assist with billing and can answer your questions.  Be assured, if an office receives notification that a claim was denied, they will investigate to see what the issue was that caused it to be rejected and take steps to correct the issue.  If your claim with us was denied, our billing specialist is working diligently to correct the problem.


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