With 8,660 CPT codes and 13,600 ICD-9 codes there were 117,776,000 code-pair combinations. With ICD-10 there are 8,660 + 87,000 possible CPTs and 13,000 + 68,000 possible diagnosis codes producing 7,586 million possible code-pairs. There is no need to calculate the various CCI code-pair/modifier combinations (52, 59, 76, 77, Rt/Lt, etc) as it produces numbers you cannot comprehend. You can now start to understand the logarithmic complexity of simply converting the LCD/NCD and CCI edits. According to inpatient or outpatient status and insurance coverage, your code-pair may need to be checked in CPT/ICD-9, CPT/ICD-10, ICD-10-PCS/ICD-9, or ICD-10-PCS/ICD-10 formatting.
The very important rumor:
Just like with ICD-9, there are “unspecified codes” within the ICD-10 code structure. These codes are not considered detailed or specific and in the ICD-10 format end in either a “9” or “0”. “chest pain” (78650/R079) and “abdominal pain” (78900/R109) are good examples of “unspecified codes” that are used daily in substantiating medical necessity. (payable diagnosis). It is strongly rumored, but yet to be officially confirmed, that CMS is not going to allow the ICD-10 “unspecified codes” to support medical necessity. Translation: CMS claims with ICD-10 codes ending in “0” or “9” will not get paid.
If CMS disallows the ICD-10 “9s and 0s”, then commercial insurances will quickly follow due to the financial rewards of not having to pay claims supported by these very common diagnosis codes.
Another concern is that the detailed information contained within ICD-10-PCS and ICD-10 coding can be used by government and private payors to later exclude coverage. Even though your center may initially be paid, payors will certainly allow their code-pair data to be reviewed by recovery contractors to recoup originally paid claims based upon the clinical data that can be mined from the ICD-10 code structure.