Monday, November 26, 2012

ICD-10 and Its Impact on Radiology

December 2011

ICD-10 and Its Impact on Radiology
By Ronald V. Bucci, PhD
Radiology Today
Vol. 12 No. 12 P. 10

Dr Jones sends his patient John to the radiology department for an x-ray of his nasal bones. John’s pet turtle bit him and, distracted by the pain, John walked into the lamppost in the driveway of his mobile home, causing him to break his nose and develop a headache.1

In the coming world of ICD-10, we’ll actually have—perhaps unbelievably—several ICD-10 codes in play for a case such as this one: W59.21XA, Bitten by turtle, initial encounter; W22.02, Walked into lamppost; Y92.024, Driveway of mobile home as the place of occurrence of the external cause; S02.2, Fracture of nasal bones; and G44.311, Acute posttraumatic headache intractable.

The upcoming transition to ICD-10 on October 1, 2013, and the new electronic transactions standards for claims that go into effect on January 1, 2012, grew out of HIPAA. The law included provisions for the standardization of healthcare information, designating standards for transactions of medical information, including claims, eligibility, and referral authorizations. On January 1, 2012, the electronic transaction standard for claims submission will change from version 4010 to 5010. On an even larger scope, the 2013 conversion from ICD-9 codes to ICD-10 codes will dramatically change the revenue cycle for all healthcare institutions. Together, version 5010 and the ICD-10 code adoptions are the solution to standardized healthcare information for HIPAA compliance.

ICD-9 codes have been around for approximately 30 years, and version 4010 has been the electronic transmission standard since the inception of electronic claims. The ICD-9 codes are used in medical billing and are the diagnosis codes for a patient’s medical conditions. A typical code might be 782.3 for edema or 486 for pneumonia. ICD-9 is the official system used to assign codes to diagnosis procedures for patient treatment in all settings. The ICD-9 codes are three to five alphanumeric characters, and there are approximately 18,000 such codes in the system. The current ICD-9 codes present some challenges. Some use outdated and obsolete terminology, lack detail, are not applicable to today's practice of medicine, and do not fit in with the HIPAA provisions.

ICD-10 will be introduced with some significant differences from ICD-9 codes. There are two types of ICD-10 codes: ICD-10-CM and ICD-10-PCS. ICD-10-CM is the diagnosis classification developed by the Centers for Disease Control and Prevention for use in all U.S. healthcare treatment settings. These codes have three to seven alphanumerics and are very similar to the ICD-9 codes. There are approximately 68,000 of these codes. ICD-10-PCS is a procedure classification system developed by the Centers for Medicare & Medicaid Services (CMS) for only U.S. inpatient hospital settings. These codes use seven alphanumeric characters, and there are approximately 72,000 of these codes. Under ICD-9 when you see a given CPT code, you can usually identify the appropriate diagnostic code from a short list of candidates. With ICD-10 codes, this number of diagnostic codes increases by nearly tenfold.

Similarities and Differences
There are some similarities and many differences between the old and the new diagnosis codes, including more characters and codes in the ICD-10 system. The main differences between ICD-9 and ICD-10 codes are shown in Figure 1.2

The CMS believes the change from ICD-9 to ICD-10 will bring improvements and benefits to patients, medical institutions, businesses, and the government. Some of the anticipated benefits are shown in Figure 2.2

ICD-10 codes were designed to be more specific than ICD-9 codes. The new codes will have details such as left or right body parts, the exact location of the condition, the activity during the initial or a subsequential encounter, and whether episodes are acute or chronic. For example, if someone fell on the ice while skating and suffered a concussion, the medical facility would have to report multiple ICD-10 codes for the occurrence: the concussion, the external cause (ice), the activity (skating), the location (where the ice rink is), and whether the injury was acute or chronic.  Specific components incorporated into the new codes include the following:2

• laterality (left, right, bilateral);

• combination codes for certain conditions and common associated symptoms and manifestations;

• combination codes for poisonings and their associated external cause;

• obstetric codes identify trimester instead of episode of care;

• character “x” is used as a fifth character placeholder in certain six-character codes to allow for future expansion and to fill in other empty characters (eg, character 5 and/or 6) when a code that is less than six characters in length requires a seventh character;

• two types of Excludes notes: one for codes and one for conditions excluded;

• inclusion of clinical concepts that do not exist in ICD-9-CM (eg, underdosing, blood type, blood alcohol level);

• numerous codes have been significantly expanded (eg, injuries, diabetes, substance abuse, postoperative complications); and

• codes for postoperative complications have been expanded and a distinction made between intraoperative complications and postprocedural disorders.

With these new codes, the inventory of diagnosis codes will increase from 18,000 to 140,000. While there may have been one code for a particular occurrence in the ICD-9 list, there may be 10 or more ICD-10 codes. For example, in the old system, there was one code for angioplasty; in ICD-10, there are approximately 854 codes. In ICD-10, there are 195 codes for suturing an artery and 312 codes that involve animals, with 72 of those dealing with birds.2 Of the 140,000 new codes that will be available, some are unique and interesting, such as the following:

• W61.42, Struck by turkey, or W61.43, Pecked by turkey;

• S45.911, Laceration of unspecified blood vessel at shoulder and upper arm level, right arm;

• S91.232, Puncture wound without foreign body of left great toe with damage to nail;

• R46.0, Very low level of personal hygiene;

• T71.233, Asphyxiation due to being trapped in a (discarded) refrigerator, assault;

• Y92.65, Oil rig as the place of occurrence of the external cause;

• T43.612, Poisoning by caffeine, intentional self-harm; and

• V04.09, Pedestrian on snow skis injured in collision with heavy transport vehicle or bus in nontraffic accident.

Impact on Radiology
Radiologists depend on the referring physician to give the order for and the reason behind an exam. They are also dependent on the physician for pertinent information related to an ordered exam. With ICD-10 codes, the amount of information required from the referring physician increases dramatically. Imaging facilities will have to acquire a much greater history for a patient when scheduling an exam for the purposes of precertification, dictation, and subsequent billing of a procedure.

Secondly, radiologists must be much more specific and detailed in their documentation and wording of a completed exam. The coding of the dictation will depend on whether the patient is an inpatient or an outpatient, since ICD-10-PCS codes are only for inpatient procedures. Therefore, the same patient can have the same exam twice, one as an inpatient and one as an outpatient, and the report codes will not be equivocal. In the ICD-10-PCS codes, there are three sections devoted to radiology. Radiologists will need to pinpoint the areas being imaged and the type of imaging being performed.3

ICD-10-PCS codes for inpatients must be matched correctly with the CPT code for the procedure. For example, suppose a patient fell in a chicken coop, suffered significant head trauma, and was admitted to the hospital. The patient was then sent for an MRI of the brain. Under the current system, the billing department would use CPT code 70551 for an MRI of the brain without contrast. The matching ICD-10-PCS code is B030ZZZ, Magnetic Resonance Imaging (MRI) of Brain. It would also be necessary to match up codes for the diagnosis in the ICD-10-CM code list, including S06.0X1A, Concussion with loss of consciousness of 30 minutes or less, initial encounter, and Y92.72, Chicken coop as the place of occurrence of the external cause.

Failure to include the appropriate codes and detailed reporting will delay reimbursement and possibly cause a loss of revenue. The challenge for radiology providers will be preventing referring physician offices from inhibiting their work because the referrers are not ready for the new codes and reporting requirements. Imaging facility managers will need to work closely with referring physicians and help them prepare for the ICD-10 introduction on which radiology’s billing depends.

Getting Ready
It is imperative that radiology providers start planning now for the October 2013 implementation. Facilities need to develop a strategic plan to make the conversion to the new system, perform training, and then test the training. Some suggestions for how to get ready include the following:

• Become familiar with the CMS website for ICD-10 (

• Perform a SWOT (strengths, weaknesses, opportunities, threats) analysis in your department on the basis of the current state of employees, IT, and environment.

• Determine your department’s future statement (what you intend to achieve) for ICD-10 implementation.

• Form a strategic business plan detailing the strategy to move to the future statement.

• Gain buy-in from management.

• Implement your strategy.

• Test, measure for successes and failures, and always improve.

A few other key points and suggestions:

• All personnel, systems, and functions in the radiology revenue cycle process should be involved in this process, from patient registration to delivering the radiology report to subsequent billing of the procedure.

• Identify challenges, including an understanding of the timeline associated with and implementation of the new codes, communication throughout your departments, IT, educating everyone in the department, and expected dysfunctions inherent to your institution.

• Develop education/training plans for all employees.

• Send radiology schedulers to medical coding classes or “boot camps” and require them to get certified in medical coding. It would be beneficial for your schedulers to know what information is needed when they schedule appointments and obtain detailed information at the first intake level.

• Enable your radiologists to go through training for dictation specifications.

• Work with referring physicians to make sure they are preparing for the ICD-10 transition and offer help to them.4

Final Thoughts
Though October 1, 2013, may seem far away now, it will be here sooner than you think. Now is the time to prepare for potential coding challenges related to the changes, which will have huge implications on the radiology revenue cycle. There is much to lose in the way of revenue if a radiology department is not ready for the new codes. If you take the time now to properly prepare and train your employees for the changes, then you will be able to take advantage of the benefits of these new codes and not interrupt your business and the financial stream that supplies your institution.

— Ronald V. Bucci, PhD, is administrative director of radiology at Akron Children’s Hospital in Ohio.


Figure 1
Comparing ICD-9 TO ICD-10

ICD-9-CM Diagnosis Codes
• Three to five characters
• First character is numeric or alpha (E or V)
• Characters 2 through 5 are numeric
• A decimal is used after three characters

ICD-9-CM Procedure Codes
• Three to five characters
• All characters are numeric

ICD-10-CM Diagnosis Codes
• Three to seven characters
• Character 1 is alpha
• Character 2 is numeric
• Characters 3 through 7 are alpha or numeric
• A decimal is used after three characters
• Use of dummy placeholder “X”
• Alpha characters are not case sensitive

ICD-10-PCS Diagnosis Codes
• Seven characters
• Characters are either alpha or numeric


Figure 2
ICD-10-CM Objectives
According to the Centers for Medicare & Medicaid Services, the up-to-date classifications in ICD-10 will provide much better data for the following:

• measuring the quality, safety, and efficacy of care;

• designing payment systems and processing claims for reimbursement;

• conducting research, epidemiological studies, and clinical trials;

• setting health policy;

• operational and strategic planning and designing of healthcare delivery systems;

• monitoring resource utilization;

• improving clinical, financial, and administrative performance;

• preventing and detecting healthcare fraud and abuse; and

• tracking public health and risk.


• “ICD-10: Acute Myocardial Infarction” by Melody Mulaik (Radiology Management, July/August 2011)

• “ICD-10 for Radiology Coding, Part 2” by Deborah Neville. (ADVANCE for Imaging & Radiation Oncology, August 31, 2011)

• “ICD-10: The History, the Impact, and the Keys to Success,” a white paper by AAPC

• “Your ICD-10 To-Do List” by John Morrissey (H&HN Hospital & Health Networks, September 2011)


1. Mathews AW. Walked into a lamppost? Hurt while crocheting? Help is on the way. Wall Street Journal. September 13, 2011. Available at:

2. Centers for Medicare & Medicaid Services. 2012 ICD-10-PCS and GEMs. Available at:

3. Neville D. ICD-10: Timing is everything. ADVANCE for Imaging & Radiation Oncology. May 2, 2011. Available at:

4. Hardy K. Preparing radiology for ICD-10. Radiology Today Digital Supplement. October 2010. Available at:





ICD10 will be impacting radiology like many other parts of the healthcare system. In short:

  • more detail on patients from the order that will be required for precertification, dictation, and subsequent billing of a procedure 
  • Radiologists will have to be more detailed in their documentation of exam reports 
  • Since ICD-10-PCS codes are for inpatient procedures only a patient can have the same exam twice 
  • ICD10-PCS codes will need to be matched correctly to the CPT codes and contain sufficient details 
  • Referring clinicians may be the source of significant challenges in your compliance if they don't include the new codes in their referrals

As the author points out - there is much to loose (information and revenue) in radiology. The time to focus is now

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