EEOICPA Bulletin No. 15-03

Attention: This bulletin has been superseded and is inactive.

EEOICPA BULLETIN NO. 15-03

Issue Date: September 18, 2015

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Effective Date: October 1, 2015

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Expiration Date: October 1, 2016

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Subject: Transition to the ICD-10-CM Coding System.

Purpose: To provide guidance on the use of the new ICD-10-CM coding system.

Applicability: All DEEOIC staff.

Background:

On October 1, 2015, the Division of Energy Employees Occupational Illness Compensation (DEEOIC) will transition to the new International Classification of Diseases, Tenth Revision, and Clinical Modification (ICD-10-CM) Coding System. The ICD-10-CM is a statistical classification and coding system used to assign appropriate codes for signs, symptoms, injuries, diseases, and other medical conditions. The transition to ICD-10-CM is federally mandated for all Health Insurance Portability and Accountability Act (HIPAA) covered entities and is occurring because ICD-9-CM reports non-specific data about patient’s medical conditions and hospital inpatient procedures. ICD-10-CM allows for greater specificity and accuracy when reporting diagnoses.

ICD-10-CM is divided into an alphabetic index, which is an alphabetic list of terms and their corresponding codes. The alphabetic index is organized in the same manner as ICD-9-CM. Codes are listed by “Main Term” which describes the disease and or/condition. The ICD-10-CM alphabetic index is divided into sections and is organized under the following main categories:

· Index of Diseases and Injury

· Index of External Causes of Injury

· Table of Neoplasms

· Table of Drugs and Chemicals

ICD-10-CM codes are assigned based on the claimant’s medical documentation (records), including, but not limited to physician notes, diagnostic tests, and surgical reports. The CE locates and enters the code that references the disease, illness or medical condition that was reported, and identifies the organ(s) or portion of the body affected by the condition. When a specific condition contains 4^th, 5^th, 6^th, or 7^th place characters the CE enters all available characters associated with that condition, not a partial code set. The CE should read all the instructional notations that appear in both the index and the tabular list of the ICD-10-CM coding books.

In order for medical bills to properly process, the Energy Compensation System (ECS) generates an eligibility file which is sent to the bill processing contractor. This eligibility file contains, among other items, the accepted condition(s) for which a claimant is entitled to medical treatment along with the corresponding ICD-10-CM code. For example, when a physician reports a diagnosis of bronchitis, not specified as acute or chronic, in the claimant’s medical records, the CE first looks up bronchitis in the alphabetic index of the ICD-10-CM coding book. Bronchitis is listed in the alphabetic index as J40. The CE then verifies that the J40 code corresponds to bronchitis in the Tabular List of the ICD-10-CM coding book. In addition, claims examiners (CE) may use the coding software found at https://www.medicalcodeexpert.com/expert which will help to identify the appropriate ICD-10-CM code. The guidance found at this website is intended to supplement the information found in the ICD-10-CM coding books. It is imperative to identify and enter the ICD-10-CM code which most specifically describes the medical condition reported in the medical records.

Examples of valid 3-character ICD-10-CM codes:

a. (1) I10 Primary Hypertension.

(2) N19 Renal Failure.

b. Examples of 4, 5, and 6-character ICD-10-CM codes:

(1) J44.9 chronic obstructive pulmonary disease unspecified (requires 4th digit).

(2) C34.11 Malignant neoplasm of upper lobe, right bronchus or lung (requires a 5^th digit).

(3) C50.512 Malignant neoplasm of lower-outer quadrant of left female breast (requires a 6^th digit).

Actions:

1. For all medical conditions with a medical eligibility begin date prior to October 1, 2015, the CE or HR will continue to use ICD-9-CM coding in ECS, development, and decisions. The medical eligibility begin date is the filing date for most conditions. However, for consequential conditions, the eligibility begin date is the filing date for the accepted underlying condition. ECS will only allow the entry of an ICD-9 code in the system if the eligibility begin date is prior to October 1, 2015. The ICD-9 code is what will be reflected throughout the system wherever ICDs are reflected. CEs and HRs will also reference ICD-9 in decisions and development letters referencing ICD codes if the filing/eligibility begin date is prior to October 1, 2015. For example, if the medical records document hypertension, unspecified, and the eligibility begin date is September 30, 2014, the CE enters (401.9) as the ICD-9-CM code in the ECS medical condition field and uses this code in the rest of their correspondence.

2. For all medical conditions with a medical eligibility begin date on or after October 1, 2015, the CE or HR will use ICD-10-CM coding in ECS, development, and decisions. If the condition is input into ECS after October 1, 2015, ECS will default to entry of an ICD-10 code. However, the system will allow entry of an ICD-9 if appropriate. If the condition is determined to be a consequential condition and the underlying condition has a filing/eligibility begin date prior to October 1, 2015, the ECS system will force the user to enter an ICD-9 code, even though the condition itself was filed after October 1, 2015. Ultimately, the medical eligibility begin date is the driving factor on whether an ICD-9 or ICD-10 code must be used on a medical condition. If the medical eligibility begin date is on or after October 1, 2015, the ICD-10 code is what will be reflected throughout the system wherever ICDs are reflected. CEs and HRs will also reference ICD-10 in decisions and development letters if the filing/eligibility begin date is on or after October 1, 2015. For example, if the medical records list a primary diagnosis of renal failure and the status effective date is October 1, 2015, the CE enters (N19) as the ICD-10-CM code in the medical condition field and uses this code in the rest of the correspondence throughout the case.

Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.

RACHEL P. LEITON

Director, Division of Energy Employees

Occupational Illness Compensation

Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, and District Office Mail & File Sections