ICD-10 changes looming amid a modern medical landscape

While some clinicians view the transition to ICD-10 as costly and burdensome, others feel that there are benefits for more accurately recording diagnoses. No matter which side of the issue, the conversion is likely to happen Oct. 1.

Many sources believe that continuing to rely on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), code set developed in the 1970s adversely affects the value of health care data. For example, ICD-9 does not meet current needs to track, identify, and analyze new clinical services, treatments, and medical technologies available for patients. But is ICD-10 the fix that offers more detail and specificity in capturing health care data?

Although some clinicians view the ICD 10 transition as costly and burdensome, particularly during a time of other regulatory mandates, others feel there are many benefits to moving to ICD-10-CM. The medical terminology and classification of diseases in ICD-10-CM are more consistent with current clinical practice than ICD-9-CM. However, like a dictionary that has thousands of words, individuals use some words very commonly while other words are rarely, if ever, used. Health care clinicians will not use all the codes in the classification system; rather they will use a subset of codes based on their practice and only the ICD-10-CM code set for diagnosis coding.

Photo by Thinkstock
Photo by Thinkstock

While much of the world has already transitioned to the ICD-10 coding system, the U.S. process has hit many snags and delays along the way. The nation began its push toward adoption of the ICD-10 code sets to replace ICD-9-CM in Health Insurance Portability and Accountability Act (HIPAA) transactions when the Department of Health and Human Services (HHS) issued a proposed regulation in August 2008, with a proposed compliance date of Oct. 1, 2011. When that regulation was finalized in January 2009, the compliance date was pushed back to Oct. 1, 2013. HHS subsequently delayed the compliance date even further from Oct. 1, 2013, to Oct. 1, 2014. When Congress enacted the Protecting Access to Medicare Act of 2014 on April 1, 2014, a provision in the law was included that prohibits the Secretary of HHS from adopting the ICD-10 code sets as the standard for code sets prior to Oct. 1, 2015—the date that currently stands as the deadline for adoption.

Understandably, clinicians prefer to spend their time on patient care, and many are concerned that a change to a new code set will require that they unnecessarily spend excessive time and/or efforts on administrative tasks that detract from care. Such concerns have led members of Congress to introduce bills to postpone or entirely abandon the conversion to ICD-10. The implications are that ICD-10 is too complex and difficult to use in part because of the increase in the number of codes and the existence of codes that will rarely be used.

Instead of creating complexity and difficulty of use, could the increased number of codes and specificity in ICD-10 make coding simpler? Much of the challenge of accurate coding results from the lack of detail with ICD-9 codes, which makes them subject to interpretation and disagreements about what they mean and when they should be used. Coding is easier when detailed and precise codes are available. Some believe that the detail in ICD-10 codes will actually decrease the claims adjudication costs associated with rejected claims and requests for more documentation, resulting in a significant administrative simplification for both clinicians and payers.

Does today's reality fit with the idea that physicians are incapable of finding the ICD-10 codes they need simply because there are more codes? It is difficult to think that expanding the code set creates complexity and increases difficulty of use for a coding system. The overwhelming majority of clinician documentation directly supports accurate code assignment in ICD-10. The greater specificity of ICD-10 will allow physicians to more accurately report the severity and complexity of their patients' conditions.

ACP has advocated for enhancement of ICD-10 with the mapping clinical terminologies. While it is clear that coding with a classification system such as ICD-10 has benefits when it comes to compiling data for secondary purposes, it is generally acknowledged that a reference terminology such as the Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) is much better at accurately capturing the nuances of health conditions and clinical care. Even leading proponents of a move to ICD-10 admit that SNOMED-CT should be used to document the course of care. Clinicians and health information technology vendors should be incentivized and encouraged to implement SNOMED-CT, or another clinical vocabulary, to code clinical information. It may be worth the time for EHR users to discuss with their vendor to see how they plan to address ICD-10 coding. Many EHR system vendors have given this a lot of thought, and they have developed tools that should ease the coding burden significantly.

A major reason for the increase in the number of diagnosis codes is attributable to ICD-10 having separate codes for left and right body parts. The removal of the left/right distinctions from the ICD-10 would decrease the number of codes by nearly 46%. Which side of the body is generally always well documented in the medical record and does not present a coding or reporting burden.

Another cause of the increase in the number of diagnosis codes is in the injury and poisoning section of ICD-10. The large reason for this increase is due to the ICD-10 requirement to specify the stage of treatment of the injury (initial treatment of the injury, follow-up treatment of the injury, or treatment of the long-term effects of the injury). As with the right/left body part distinctions, the stage of treatment of an injury is generally readily known and does not present a coding or reporting burden. For many physician specialties, the difference in the number of codes is fairly modest and most of the codes contain the same detail familiar to users of ICD-9. Where there is new terminology in the new codes, it often replaces obsolete terms in ICD-9.

Some have argued that eliminating this change—not implementing ICD-10—would lessen the total burden of change in other areas. However, the case is being made that tother payment and regulatory reforms depend on the availability of more detailed and precise diagnosis and procedure data. That ICD-10 will improve national health care initiatives such as Meaningful Use, Value-Based Purchasing, payment reform, and quality reporting. Without ICD-10 data, there will be serious gaps in the ability to extract important patient health information needed to support research and public health reporting and move to a payment system based on quality and outcomes.

Given the importance of precise diagnosis and procedure codes to health care reforms already underway, is the failure to have access to detail and precision still a viable option? The fact is, no matter which side one is on, we must all prepare for ICD-10, as the implementation date is less than 10 months away. There will be efforts to delay it—ICD-10 has been delayed every year since 2011—but there may not be another delay this time.