As of October 1, 2015, the new International Classification of Diseases, Tenth Revision (ICD-10) is the required diagnosis code set to be used for billing all claims to insurers. Every healthcare stakeholder is affected by the transition to the expanded ICD-10 code sets, as these changes impact medical coding operations, software systems, reporting, administration, registration, and more for all entities and providers covered by the Health Insurance Portability and Accountability Act (HIPAA), not only those submitting claims to Medicare.

Coding Compliance

CMS and commercial payers require a valid code to be reported for reimbursement, and it will be important to follow the ICD-10 guidelines to complete the code set. While M05 is a correct category to identify rheumatoid arthritis with positive rheumatoid factor, ICD-10 coding guidelines indicate that at least five characters are necessary for this to be a valid/billable code. A sample of a valid code for RA with rheumatoid factor is M05.79 – rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement.

Understanding the coding guidelines and applying the most valid diagnosis code to your claim will minimize any negative impact on your practice’s financial and operational metrics. The following are key indicators for accurate billing and timely processing.

  • Claims with date of service on October 1, 2015 and after should be submitted with only ICD-10 diagnosis codes.
  • Claims for service September 30, 2015 and prior should still be submitted with ICD-9 diagnosis codes; regardless of when it is billed.
  • Check your commercial payer's website for information about ICD-10 implementation and a method of contact for issues.

Keep in mind, the implementation of ICD-10 is only for diagnosis coding and will not affect CPT coding for outpatient procedural services.

Download the ACR crosswalk with the top 50 commonly used rheumatology codes as well as the rheumatology specific superbill to be used as a quick guide for coding and billing. (Note: these should not take the place of the official ICD-10 coding manual as there are key guidelines and convention that may not be included in the crosswalk due to space.)

Additional steps to ensure practice efficiency include:

  • Monitoring all explanations of benefits (EOB) and payments for high dollar claims to verify they are being processed correctly.
    • If they are not, review the claim and confirm that a valid ICD-10 code was used and the date of service. If all is correct; contact the carrier to see if this can be resolved.
    • If a phone call to the carrier does not take care of the issue; contact the ACR practice management department at practice@rheumatology.org.
  • For any issues with Medicare claims, contact CMS directly by emailing the ICD-10 ombudsman at ICD10_Ombudsman@cms.hhs.gov.
  • For any issues with your practice management systems, electronic health records (EHR), billing vendors, or clearinghouses, contact the vendor immediately for assistance.

ACR staff has developed a stronger communication and collaboration platform that can help keep better track of any ICD-10 implementation issues and coding errors before and after October 1. For faster response to questions or concerns, members can send questions to practice@rheumatology.org.