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How Does ICD-10-CM Affect You?

Diagnostic coding requirements are becoming more mainstream, and they could affect your practice. Find out how you can prepare for the change.

October 1, 2015 was a date that forever changed how diagnoses codes are submitted for both medical and dental claims. This is the date that the long awaited ICD-10-CM code set was implemented. Prior to the introduction of ICD-10-CM, dentists only reported a diagnosis code when submitting a medical claim. Since that date, there has been a growing trend toward requiring dentists to report diagnoses codes on dental claims.

This change has been driven by a mandate from the Centers for Medicare and Medicaid Services (CMS) which stated that effective October 1, 2015, all HIPAA-covered entities were required to implement the ICD-10-CM diagnosis code set. Medicaid is a HIPAA entity, as are medical and dental clinics. This mandate has been interpreted to include Medicaid dental claims. Medicaid plans started implementing this requirement early, and since October 1, 2015 many other states have followed suit. At the time of this writing at least 13 states are requiring ICD-10-CM codes to be reported on all Medicaid dental claims. Dental claims received without at least one diagnosis code are rejected.

In addition to Medicaid, health insurance purchased under the Affordable Care Act (ACA) includes mandated pediatric dental benefits. These benefits are sometimes administered as embedded benefits through a medical policy. Some of these plans allow the dentist to file claims on the 2012 ADA Dental Claim Form (the latest dental claim form) using dental codes. However, an ICD-10-CM diagnosis code may also be required, and ADA claim forms submitted without a required diagnosis code may be rejected. Moreover, other government payors such BCBS Federal are now also requiring diagnoses codes to adjudicate dental claims.

Government payors, including Medicaid, were the first to require diagnoses codes for dental claims, but it is expected that private payors will also adopt the requirement in the future. In fact, some Delta Dental plans began to require the 2012 ADA Claim Form from providers as of October 1, 2015 (dates of implementation vary by plan). That claim form has a field for up to four ICD-10-CM diagnoses codes. While this notification doesn’t include a requirement for using diagnoses codes, it is an indicator that this requirement is tied to ICD-10-CM implementation.

What should I do to prepare?

If you do not currently report ICD-10-CM diagnoses codes on your dental claims, it is possible that your practice may be minimally impacted by ICD-10-CM. However, with the understanding that most dentists will eventually need to report a diagnosis code, you should follow these steps to prepare for the time when you may be required to do so:

  1. Become familiar with the most common ICD-10-CM codes used in dentistry. There are 69,000 diagnosis codes but only a small percentage pertain to dentistry.
  2. Make sure the ICD-10-CM codes that apply to your practice are installed and cross-coded on your system. Visit https://www.dentrix.com/support/icd-10 for more information about Dentrix and ICD-10.
  3. Develop a protocol to allow communication between providers and staff members regarding accurate reporting of ICD-10 codes. Ultimately it is the treating dentist’s responsibility to ensure that most accurate diagnosis code is reported, not a selection by a staff member.
  4. Review your clinical documentation. Accurate clinical documentation is important to patient care and to reporting a correct diagnosis code. ICD-10- CM coding requires detailed, specific information from the clinical notes, not a verbal discussion with the dentist.

Understanding the basics of ICD coding is the first step in preventing claim rejections. Remember, you are communicating to the insurance payor not only the procedures performed but also why the procedures are necessary, without having to submit wordy narratives and other supporting documentation. If you do this, when your payors start requiring diagnoses codes you can keep getting paid without interruption.


Learn More

Visit https://www.dentrix.com/support/icd-10 to learn more about Dentrix and ICD-10.

Read “Cross coding ICD-10-CM codes with AMA codes” in the Dentrix help or “Attaching Diagnostic Codes to Procedures in the Progress Notes” for more information.


By Dr. Charles Blair, CEO of Dr. Charles Blair & Associates

Dr. Charles Blair is the publisher of several publications, including Coding with Confidence, Administration with Confidence, Diagnostic Coding for Dental Claim Submission, Medical Dental Cross Coding with Confidence, and the Insurance Solutions Newsletter. He is the founder of www.practicebooster.com, which optimizes insurance administration and aids in maximizing reimbursement.

Originally published in Dentrix Magazine, Fall 2016