What is the ICD-10?

The ICD-10 is an international coding system used by healthcare administrators and clinicians worldwide. ICD is an acronym for the International Classification of Diseases, a classification system governed by the World Health Organisation since 1948. ICD-10 is the tenth revision of this coding system, with the latest version being used since 2019.

More recently, the WHO published a further detailed ICD-11 for utilisation on 1 January 2022. Health administrators across the world are now in the process of updating their coding systems. Currently, the South African healthcare industry is still utilising the ICD-10 until advised accordingly by the respective Governing bodies.

The ICD-10 contains unique codes related to primary, secondary, and tertiary care diseases and the causes of death. These codes are used by various clinicians, health administrators, researchers, and policymakers. Insurance companies also use these codes to support health or death-related financial claims.

Medical aids and medical insurance companies use two types of codes to process billing and pay-outs:

1. ICD-10 codes indicate a specific diagnosis or disease
2. Tariff codes indicate a specific treatment or service provided in relation to that diagnosis.

Tariff codes are unique to each country as these are related to the cost at which a service provider can claim. In South Africa, the pricing for each tariff code is determined by the Department of Health and published annually as the National Health Reference Price list (NHRPL). This list is available to medical schemes and insurance companies as a reference for their reimbursement policies. The tariff codes are processed with the ICD-10 code to assess the claim’s accuracy and calculate how much will be paid to the service provider.

It is, therefore, of utmost importance that the ICD code is correct when submitting a patient’s bill. If the code is incorrect or does not correspond with the quoted tariff code- the insurance company may deny a pay-out of the claim.

ICD-10 allows for accurate recording and monitoring of diseases. Information provided by these codes describes causes of death, diseases, injuries, symptoms, reasons for encounters, factors influencing health status, and external disease causes.

Some benefits of using these codes globally include the following.

• Consistent and standardised reporting worldwide.
• Easy storage, retrieval, and analysis of health information for evidenced-based decision-making.
• Sharing and comparing health information between hospitals, regions, and countries.

It also assists clinicians and health administrators keep track of previous diagnoses to monitor trends, adjust management plans and pre-empt future complications.

Additional Coding

The South African coding standards stipulate that all “S and T codes” related to injuries and poisons must be accompanied by a secondary ICD-10 code known as an External Cause Code (ECC). The ECC classifies events, circumstances and conditions that may have caused the injury/poison. The ECC codes can never be used on their own.

For example, if you fell from a tree whilst gardening and fractured your femur (upper leg). In that case, the ICD-10 codes might look like this:

Injury (primary diagnosis): S72.3 “Fracture of shaft of femur”

Cause (secondary diagnosis): W14.03 “Fall from the tree, at home, whilst engaged in other types of work”.

Due to the complexity of coding and the need for accurate diagnosis and claims submissions, many clinicians, hospitals, and health-related companies have designated administrators who are trained in ICD-10 and Tariff code systems. Some doctors may use a third party to record diagnoses and services on their behalf to ensure the codes are done meticulously.

How Do I Find ICD-10 Codes?

Suppose you require more information on which code has been used for your diagnosis for disputed claims, unpaid claims, or denied pre-approvals. In that case, you can find them in the diagnosis section of the summary provided by your healthcare provider.

To look up the ICD-10 code, visit the WHO ICD website, and use their free searchable database.

Insurance Reimbursement

When your healthcare provider submits your bill to the insurance company for reimbursement, each service is described by a Tariff code. These codes are matched to an ICD-10 code for the diagnosis. The company may deny payment if the two codes do not align.

You can use the ICD-10 code to confirm that you or your healthcare provider have submitted the correct claims for a situation: hospital admissions, specialist consultations, and daily GP visits.

Affinity Hospital Claims

At Affinity, we use ICD-10 codes to process and pay your claims when admitted into the hospital. Before going into the hospital, you can obtain pre-authorisation from our 24-hour hospital pre-authorisation line on 0861 11 00 33. Once admitted, the hospital or treating physician will record the ICD-10 code and related services rendered. These will be reviewed to process and pay any claims related to the hospital admission.

Claim for GP Visits

General practitioner consultations require pre-authorisation. If you visit a doctor who may not be on the Affinity Health network, you must pay an upfront full consultation fee. The health care provider should provide you with a statement with the services, ICD-10 code and payment details. This can be used for reimbursement from Affinity Health Insurance.

For further assistance with reimbursement, please email the detailed account and a signed Affinity Health reimbursement form to claims@affinityhealth.co.za.