Working in billing and revenue cycle management (RCM) means understanding a lot of different codes and code sets. There are current procedural terminology (CPT) codes, evaluation and management (E/M) codes and diagnosis codes.
But unlike CPT or E/M codes, diagnosis codes don’t change from year to year. They’re classified under the International Classification of Diseases (ICD), an international code set created by the World Health Organization (WHO) and adopted by WHO’s 194 countries (member states).
The U.S. currently uses ICD-10-CM, a code set with specific clinical modifications (CM) to the global ICD-10 codes. But eventually, the U.S. will shift to ICD-11 coding, and healthcare organizations across the country need to be ready. The ICD-11 codes will affect reporting and monitoring of different diseases, ultimately influencing healthcare funding, payer rules and reimbursement rates.
Let’s dive into the key features of ICD-11 coding and how it differs from the current ICD-10-CM.
What Is ICD-11?
Adopted by WHO in May 2019, ICD-11 creates specific codes for diagnoses. ICD-11 includes many updates to reflect current scientific knowledge. It went into effect on January 1, 2022, but countries can transition to the new code set on their own time.
ICD-11 also has a new name: ICD-11 for Mortality and Morbidity Statistics (ICD-11-MMS). This name more accurately reflects the purpose of ICD-11: to provide consistent reporting, measuring and comparing of mortality (causes of death) and morbidity (injuries and diseases) data worldwide.
How Does ICD-11 Coding Differ From ICD-10?
ICD-11 coding reflects more current scientific data. It’s also easier to use and has “more meaningful clinical content” than ICD-10.
Moreover, the WHO designed ICD-11 to be “digital health ready,” meaning it will easily integrate with different health IT systems, including electronic health record (EHR) platforms.
ICD-11 coding includes 28 chapters compared to the 22 chapters in ICD-10. New core chapters include:
- Diseases of the immune system
- Sleep-wake disorders
- Conditions related to sexual health
The WHO also included more than diseases in ICD-11; the codes cover signs and symptoms, causes, disorders and more.
The ICD-11 codes have a different, more detailed categorization and structure than ICD-10 codes. There are more than 55,000 ICD-11 codes vs. the 14,000 in ICD-10.
Despite the higher level of detail, ICD-11 coding is more straightforward. It also allows for extension codes and cluster coding. This structure helps providers record more detailed and precise information within the diagnosis code, such as laterality, anatomy, manifestation or severity of a condition.
Extension codes replace the ICD-10 adjunct codes. You can use them to describe the dimensions of an injury or other external causes.
For example, you would add the extension code XB32 to show which breast (in this case, right) for a malignant neoplasm (2D1Z). You can also add manifestations, such as a panic attack (MB23.H) for social anxiety disorder (6B04).
ICD-11 also allows for cluster coding, which means you can combine multiple codes to describe a diagnosis in detail. For example, the cluster code 2D1Z&XB32&XC56 describes:
- Malignant neoplasm of the breast, unspecified: 2D1Z
- Laterality (right): XB32
- Specific anatomy (upper outer quadrant of breast): XC56
Another cluster code example for behavioral health is 6B04/MB23.H. This code describes:
- Social anxiety disorder (6B04)
- Manifestation: Panic attack (MB23.H)
What Are the Benefits of ICD-11 Codes?
Although ICD-11 has yet to roll out in the U.S., it has many benefits over ICD-10. For one, the new code set reflects current scientific knowledge, which has come a long way since ICD-10 was adopted in the 1990s.
Moreover, because the U.S. uses a clinical modification for ICD-10 (ICD-10-CM), its reporting and data are inconsistent with the other WHO countries using ICD-10. A shift to ICD-11 will help create more consistent reporting around the world.
Here are a few other benefits to ICD-11:
Digital Health Ready
ICD-11 is the first fully electronic ICD code set. It runs on a central platform that connects to various types of software. There’s also an API that you can use in different health IT platforms.
An online, index-based search makes finding the correct code and extension codes easy. The coding tool also builds the cluster code for you.
ICD-11 coding is more flexible and straightforward than previous ICD code sets. You can use simple coding or add extension and cluster coding to add more detail to a diagnosis.
Easier to Update
Because of its digital format, ICD-11 will be easier to update. Ultimately, this may mean there won’t be a need for an ICD-12.
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When Will ICD-11 Be Implemented in the United States?
Although the WHO officially rolled out ICD-11 in January 2022, the U.S. hasn’t yet adopted the new code set. It’s a significant undertaking to migrate to this new system — the WHO estimated at least a five-year transition period for countries that already have a sophisticated documentation system like the U.S.
According to the American Academy of Professional Coders (AAPC), the U.S. may migrate to ICD-11 coding as early as 2025. If the U.S. decides to add a clinical modification to ICD-11 (as it did with ICD-10), the ICD-11-CM would likely roll out by 2027.
Whether the U.S. will meet that 2025 timeframe is unclear, but keep your eyes peeled for official migration announcements. After all, it will be a big shift for providers in all specialties — a shift that will hopefully improve health research, funding and outcomes across the globe.
Lean on Gentem for Coding Expertise
When you partner with Gentem for medical billing and RCM, you get a team of Certified Professional Coders (CPCs) who verify every claim, reducing costly denials and rejections. Our coders hold Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Orthopedic Surgery Coder (COSC) and Certified Obstetrics Gynecology Coder (COBGC) certifications (among others). With this resource, your practice will increase revenue from collections and spend less time tracking down reimbursements.
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