Reimbursement
ICD-10-CM / ICD-10-PCS
In one line
Diagnosis (CM) and inpatient procedure (PCS) coding systems used in U.S. claims.
Definition
ICD-10-CM codes are diagnosis codes used across all care settings; ICD-10-PCS codes describe inpatient procedures and drive MS-DRG assignment for hospital reimbursement.
ICD-10-CM is maintained in the US by CDC's National Center for Health Statistics, and ICD-10-PCS by CMS, with annual updates effective October 1. New device procedures can apply for a new PCS code through the ICD-10 Coordination and Maintenance Committee, which is often a step toward NTAP. Accurate diagnosis coding also supports medical necessity on claims.
Why it matters
Securing a unique ICD-10-PCS code can materially change inpatient payment for a new procedure or device. CMS holds public ICD-10 Coordination & Maintenance meetings twice yearly.
Common pitfalls
- •Assuming that a MedTech product automatically receives a unique ICD-10-PCS code without active engagement in the CMS coordination and maintenance process is a common mistake.
- •Failing to understand the specific criteria and timelines for proposing new ICD-10 codes can lead to delayed market access or suboptimal reimbursement for new technologies.
- •Incorrectly coding diagnoses (ICD-10-CM) or procedures (ICD-10-PCS) can result in claim denials, audits, and potential penalties.
- •Overlooking the distinction between ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures can lead to mischaracterization of a device’s impact or use.
Sources
- CMS ICD-10 · CMS