ICD-10 Code
International Classification of Diseases, 10th Revision
Apr 24, 2017

ICD 10 CM - Diagnosis Codes

Definition

  • When the code set is implemented on October 1, 2015, it will replace ICD-9-CM to report medical diagnoses on claims;
  • When the code set is implemented, all providers, including physicians, will use it in U.S. health care settings;
  • Providers select codes based on documentation in the patient’s medical record; and
  • CDC developed and maintains the code set.

Payment Information

  • When ICD-10 is implemented on October 1, 2015, and physicians report diagnosis codes on claims, in general, the MAC will use the codes to determine coverage, not to determine the amount CMS will pay for furnished services; and
  • When ICD-10 is implemented, inpatient providers will report ICD-10-CM diagnosis and ICD-10-PCS procedure codes on claims, which the MAC will use to assign discharges to the appropriate ICD-10 MS-DRG.

ICD 10 PCS - Procedure Codes

Definition

  • When the code set is implemented on October 1, 2015, providers will use it to report procedures performed only in U.S. hospital inpatient health care settings on claims
  • Physicians will not use the code set to report their services, including ambulatory services and inpatient visits;
  • Providers select codes based on documentation in the patient’s medical record; and
  • CMS developed and maintains the code set.

Payment Information

  • When ICD 10 is implemented on October 1, 2015, physicians, suppliers, outpatient facilities, and hospital outpatient departments will:
    • Continue to report and receive payments for furnished services, including physician visits to inpatients, based on CPT and HCPCS codes; and
    • Use only ICD-10-CM (diagnosis) codes, not ICD-10-PCS (procedure) codes, on claims; and
  • When ICD-10 is implemented, inpatient providers will report ICD-10-CM diagnosis and ICD-10-PCS procedure codes on claims, which the MAC will use to assign discharges to the appropriate ICD-10 MS-DRG.

HCPCS Codes

Definition

  • Level I codes and modifiers are the CPT codes; and
  • Level II codes and modifiers primarily identify products, supplies, and services that are not included in the CPT codes (such as ambulance services; drugs; devices; and durable medical equipment, prosthetics, orthotics, and supplies).

Payment Information

  • When providers report HCPCS codes on claims, the MAC uses the codes to either determine coverage or the amount CMS will pay for furnished services (less beneficiary coinsurance and copayments).

HCPCS Level I

Definition

  • The code set providers use to report medical procedures and professional services furnished in ambulatory/ outpatient settings, including physician visits to inpatients; and
  • The American Medical Association (AMA) developed, copyrighted, and maintains the code set.

Payment Information

  • When providers report Level I HCPCS CPT codes on claims, the MAC uses the codes to either determine coverage or the amount CMS will pay for furnished services (less beneficiary coinsurance and copayments); and • When ICD-10 is implemented on October 1, 2015, physicians, suppliers,
  • When ICD-10 is implemented on October 1, 2015, physicians, suppliers, outpatient facilities, and hospital outpatient departments will:
    • Continue to report and receive payments for furnished services, including physician visits to inpatients, based on CPT codes;
    • Use only ICD-10-CM (diagnosis) codes, not ICD-10-PCS (procedure) codes, on claims; and
    • Continue to follow CMS guidance when reporting CPT codes, including CPT modifiers for laterality.

HCPCS Level II

Definition

  • The code set providers use to report medical items, supplies, procedures, and certain professional services that are not described by any CPT codes; and
  • CMS maintains the code set, with the exception of the code set for dental services (D-codes). The American Dental Association (ADA) developed, copyrighted, and maintains the D-codes.

Payment Information

  • When providers report Level II HCPCS codes on claims, the MAC uses the codes to either determine coverage or payment for furnished items and services (less beneficiary coinsurance and copayments); and
  • When ICD-10 is implemented on October 1, 2015, physicians, suppliers, outpatient facilities, and hospital outpatient departments will:
    • Continue to report and receive payments for furnished services, including physician visits to inpatients, based on HCPCS codes;
    • Use only ICD-10-CM (diagnosis) codes, not ICD-10-PCS (procedure) codes, on claims; and
    • Continue to follow CMS guidance when reporting HCPCS codes, including HCPCS modifiers for laterality.

When ICD 10 was implemented on October 1, 2015, it did not affect physicians', outpatient facilities', and hospital outpatient departments' use of CPT codes on Medicare Fee-For-Service claims. Providers should continue to use CPT codes to report these services.