The ICD-10 Diagnosis Codes Decide Whether or Not Medicare Will Pay

How ICD-10 codes affect your care and your wallet

ICD-9 ICD-10 diagnosis code
What diagnosis code should a doctor use when she treats your sore throat?. B2M Productions/Photographer's Choice RF/Getty Images

It takes years of education and training to teach doctors the skills needed to evaluate a patient, make a diagnosis, and treat that person according to the standard of care. Now the rules have changed. A new layer of complexity has been added that may affect whether or not your insurance plan will pay for your care.

How Medical Billing Works

You could take a course to understand the intricacies of medical billing, but what you really need to know are the aspects of billing that affect you on a personal level.

In simple terms, your doctor evaluates you, picks a diagnosis code to match your condition and chooses a billing code based on the complexity of your visit. Any tests ordered must also be linked to the diagnosis code. This information is then directed to your insurance company, Medicare included, so your doctor gets paid for his service. 

If your doctor does not pick the right diagnosis code, it is possible your insurance plan will not pay for the care you received. That leaves you paying not only a copay or coinsurance for the test or visit but the full dollar amount.

The Change from ICD-9 to ICD-10 Codes

The International Classification of Diseases is a tool box of diagnosis. In its 10th edition (ICD-10) since 1990, this list of diagnoses is used worldwide to track disease and mortality rates. Standardizing diagnosis codes also improves the ability to track health initiatives, monitor healthcare trends and respond to health threats.

 The United States, however, was slow to adopt the most recent codes and did not transition from ICD-9 to ICD-10 until October 2015.

There are more diagnosis codes than you can imagine. The number of possible codes your healthcare provider must choose from exponentially increased in October 2015. There are 155,000 codes available in ICD-10 as compared to the 17,000 codes in ICD-9.

This increased specificity will make it harder for doctors to find the codes they need to get insurance to pay. It has been anticipated that billing errors will be on the rise because of the transition to ICD-10. More billing errors could lead to you paying more than your fair share.

Choosing the Right Code

To get an idea of the complexity of ICD-10, look at common upper respiratory complaints. Allergic rhinitis (a runny nose from allergies) has at least six different codes from which to choose, pneumonia 20 codes, asthma 15 codes, influenza 5 codes, sinusitis 21 codes, and sore throat 7 codes. Those are the easy ones.

Complicated conditions like hypertension have many layers to the diagnosis that show how the condition relates to heart disease, kidney disease, pregnancy, and more. Diabetes has even more codes. There are even three codes for being struck by a falling object on a sailboat! You can amuse yourself and search for codes on the Centers for Medicare and Medicaid (CMS) website. Regardless, it is easy to see how it could be a challenge to find the right diagnosis codes when there are so many new codes to choose from.

Appealing Your Case

For a time, you may not feel the brunt of the ICD-10 transition. This is because a grace period has been put in place by CMS to give doctors leniency for 12 months. As long as doctors code in the right category for a disease, even if it is not the exact perfect code, they will not be penalized by CMS and your care should be covered. Private insurance plans may have different rules.

Come October 2016, the grace period will be lifted and we will see the real effects of medical billing errors. If at any time you receive a bill that you do not think you should be required to pay, contact your doctor's office. It is possible they have used the wrong ICD-10 code. Your doctor may be able to change the diagnosis code to one that gives you the insurance coverage you need.


The American Health Information Management Association ICD-10 FAQs. Accessed March 8, 2016.

Beckman K. Coding Common Respiratory Problems in ICD-10. Fam Pract Manag. 2014 Nov-Dec;21(6):17-22.

Centers for Medicare and Medicaid Services. CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10 Frequently Asked Questions. Accessed March 8, 2016.

Centers for Medicare and Medicaid Services. ICD-10 Code Look Up. Accessed March 8, 2016.

World Health Organization. International Classification of Diseases (ICD). Accessed March 8, 2016.

Continue Reading