The ICD-10-CM Foundation and Background

Definition of Terms

In order to be able to discuss the transition from ICD‐9‐CM to ICD10‐CM, you first need to understand
the “language” in which the new coding process communicates. Following are terms you need to know.

Important Terms for ICD-10

Covered Entity: Providers, payers and clearinghouses who conduct specific administrative transactions electronically.

EDI: Electronic Data Interchange. Usually used in conjunction with the transmission of health data between providers and clearinghouses/insurance payers.

EHR: Electronic Health Record. This acronym is interchangeable with EMR (Electronic Medical Record). Generally means software that digitally stores patient charts and automates patient care functions such as computerized order entry and ePrescribing.

GEMs: “General Equivalence Mapping” is an approximate conversion and reference
mapping system that attempts to include all valid relationships between the codes in ICD‐9‐CM and ICD‐10‐CM. The relationships can be “one to many,” “many to one,” and in some cases, “one to one.” GEMs is an excellent tool to be used for ICD‐10‐CM staff training and chart auditing.

HIPAA: Health Insurance Portability and Accountability Act of 1996 established not just new rules for ensuring the privacy of health records but also set standards for the electronic transaction of interchanged health data.

HHS: The U.S. Department of Health and Human Services.

ICD‐9‐CM: The Diagnosis Coding lexicon currently in use. It is outdated, inflexible and many categories are full. ICD‐9‐CM contains approximately 13,000 diagnosis codes using a 5 numeric character structure and is electronically communicated using the traditional v.4010 data format.

ICD‐10‐CM: The Diagnosis Coding lexicon mandated for use on Oct. 1, 2014. Developed by World Health Organization (WHO), and used in most industrialized nations, this code structure requires a new data format (v.5010) because it contains up to 7 alphanumeric characters unlike the 5 numeric characters used in ICD‐9‐CM. Comprised of approximately 68,000 codes, it requires providers to code and document to much greater “specificity”.

ICD‐10‐PCS: For use in Inpatient Hospital procedure coding only. Physician outpatient settings will continue to use CPT‐4 to report procedures and services.

O.N.C.: Stands for the Office of the National Coordinator for Health Information
Technology and is a division of the U.S. Department of Health and Human Services (HHS). Under ONC, there are three bodies that can certify Electronic Medical Record technology for “Meaningful Use”.

Placeholder: When a seven character ICD‐10‐CM code requires a seventh character but the sixth position character has no function (e.g. no category, etiology or location), a “placeholder” consisting of the letter “X” is inserted in the sixth character position in order to hold that place in the code so that a seventh character can be used.

PM Software: “Front End” practice management software that schedules, tracks and codes patient encounters. (As opposed to the automated charting functions of EMR).

R.A.C. Audit: Recovery Audit Contractor ‐ The RAC Program’s purpose is to reduce improper Medicare payments and implement actions to prevent future improper payments. The demonstration program in 3 states started in 2005. 3 more states were added and by 2008, $1.03 billion were recovered from improper payments.

Role Based: Used to describe a type of training strategy that focuses the amount and type of training on job classification rather than general training for an entire group. In this context for example, you should consider a different level of training for your physicians (documentation training) than for your coding staff (full ICD‐10‐CM training).

Sequela: An aftereffect of a disease, condition or injury. Also called a “late effect.”

Specificity: In this context, “specificity” is a term used to describe choosing the diagnosis code that is the most descriptive possible given the available provider documentation.

V.5010: An electronic data reporting format scheduled replacing V.4010 on Jan. 1, 2012. Electronic testing of transactions using V.5010 commenced on Jan. 1, 2011. This new data format is required because the new ICD‐10‐CM codes are comprised of up to 7 alpha numeric characters and the old data format currently in use (v.4010) is unable to accommodate ICD‐10‐CM. (On Nov 17, 2011 CMS announced a 90‐Day period of enforcement discretion.)

W.E.D.I.: Comprised of a cross section of the health care industry, the Workgroup for Electronic Data Interchange (WEDI) is the leading authority on the use of Health IT to improve healthcare information exchange in order to enhance the quality of care, improve efficiency and to reduce costs of the American healthcare system. Formed in 1991 by the Secretary of Health and Human Services (HHS), WEDI was named in the 1996 HIPAA legislation as an advisor to HHS and continues to fulfill that role today.

WHO: World Health Organization is made up of representatives from numerous
countries that create policy and develop health programs to be adopted on a
world‐wide basis. The WHO developed ICD‐10.

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