The United States is one of the last economically developed nations to transition from ICD-9 to the International Classification of Diseases, 10th Edition, also known as ICD-10. The transition is no small task. On Oct. 1, 2013, our country will begin using the most comprehensive coding system in the world, a set featuring approximately 150,000 diagnosis and procedure codes. More than 100 other countries, including Germany, Canada, Australia and New Zealand already have implemented customized versions of ICD-10 tailored to their single-payer health systems. By the time our implementation mandate arrives, almost 20 years will have passed since the first of our international neighbors transitioned to the ICD-10 code set.

The single greatest challenge physicians will have with ICD-10 is the need for improved documentation. ICD-10 will require physicians to spend additional time and effort documenting to ensure that coders have the appropriate information to complete claims.  While the transition will not be easy for physicians, it is important to remember that the rules governing documentation are not changing. Ask any physician/coder team that has been audited and they will tell you that the documentation guidelines in ICD-9 are very specific, but the codes do not keep up with the documentation requirements due to the fact that the ICD-9 codes do not offer the granularity necessary to adequately reflect the guidelines. With ICD-10, for the first time we will have a clinical classification system that is sophisticated and granular enough to keep up with the regulations. Let’s take a moment to explore both ICD-10 coding systems.

Coding ICD-10-CM

ICD-10-CM, the diagnostic subset, has some additions and changes – the most obvious being the design of the code. Diagnosis codes in ICD-10 have up to seven alphanumeric characters, compared to the five-character system used today in ICD-9. Physicians should expect the learning curve for ICD-10-CM to be much smoother than that of the ICD-10-PCS procedural counterpart. The rules, conventions and guidelines in ICD-10-CM are very similar to what currently appears in ICD-9-CM, with only a few changes.

Let’s use chronic kidney disease (CKD) as an example. Currently, coders are required to make code selections for this disease based on severity, a concept that does not change in ICD-10. Classification of CKD in ICD-10 continues to be based on severity represented by stages I-V, and the disease is assigned from the N18 section of the ICD-10-CM system. End-stage renal disease (ESRD) still only is assigned when it is actually documented, and it is also assigned from the N18 section. For cases in which patients have CKD in conjunction with other diseases, such as diabetes mellitus or hypertension, the ICD-10 book still directs the coder in the proper sequencing of the codes. Furthermore, there are still codes to represent complications of transplants, but in this area there is greater specificity available to represent complications adequately. A newer concept in ICD-10-CM is the multitude of combination codes available. What took us two or three codes under ICD-9-CM now only may take one combination code in ICD-10-CM. Take a look at this example:

  • A patient diagnosed with malignant hypertension and stage V chronic renal disease is admitted to the critical care unit. The patient is now in acute renal failure with acute cortical necrosis.
  • First listed diagnosis: I12.0, Hypertensive chronic kidney disease with stage V chronic kidney disease or end stage renal disease.
  • Second listed diagnosis: N18.5, Chronic kidney disease, stage V.

Coding ICD-10-PCS

The procedural subset ICD-10-PCS is unlike anything we have seen in the coding world before. The ICD-10 procedure codes are vastly different from what we currently use, as they are table-based, seven-character alphanumeric codes. The ICD-10-PCS subset will be used primarily in the inpatient facility coding arena, but knowledge of the codes at the practice level will be necessary for revenue analysis. The key to building an ICD-10-PCS procedure code is finding the correct table. This new process will require coders to attain more advanced anatomical and pathophysiological expertise; a medical terminology class no longer will be enough. Coders will need to complete a college-level anatomy and physiology course to help maneuver within ICD-10-PCS. Take a look at this example:

  • An inpatient diagnosed with gallstones opts for an elective laparoscopic cholecystectomy.
  • Procedure: 0FT44ZZ, Laparoscopic cholecystectomy

Coders will need to understand body systems, root operations, body parts, approaches and devices. Root operations could pose serious issues for coders who do not have thorough understanding of anatomy and how procedures are performed. For example, coders will be required to differentiate between the following: excision vs. resection/inspection, occlusions vs. restrictions, release vs. division, transplantation vs. administration, etc. Medical practices should watch for the availability of reputable anatomy classes specific to ICD-10; many organizations are conducting these classes now or will begin conducting them soon. Furthermore, specialty physicians should look to their specialty societies for guidance. Many specialty societies are developing materials to help smaller practices navigate ICD-10 implementation. The bottom line is that physicians should be seeking out any available resources, whether from a specialty society or even from a payer. Most payers are further down the implementation pathway by now and have valuable knowledge and resources to share.

Effective ICD-10 implementation is critical at the practice level to ensure that you are able to remain in the game on and after Oct. 1, 2013. If you are not ready for ICD-10, you may be risking your business. ICD-10 will change healthcare as we know it, and avoiding it will not make it go away. The likelihood of ICD-10 being postponed is low.

Not being prepared for the federally mandated transition will make the process more costly, more difficult, more resource-intensive and more stressful. By taking the necessary steps today to understand the impact that ICD-10 will have on your organization tomorrow, you will lessen the costs associated with implementation and ensure that you have the appropriate systems, technology and people in place to conduct business as usual.

Despite recent efforts of some organizations in the industry, there are absolutely no signs coming out of Washington, D.C. that point toward a delay in ICD-10 implementation. On the contrary, documentation coming out of the Centers for Medicare & Medicaid Services (CMS) states that Oct. 1, 2013, is the final deadline for ICD-10 compliance. Regardless of what is heard in the press, savvy healthcare organizations will launch and develop implementation plans throughout 2012, remaining on track for a 2013 compliance date. Above all, remember – it’s an exciting time to be in healthcare.

About the Author

Annie Boynton is a multi-credentialed coder and the director of 5010/ICD-10 communication, adoption and training for UnitedHealth Group. She is a developing member of the AAPC’s ICD-10 training team. Annie frequently speaks and writes about coding matters, including ICD-10 and 5010 implementation.

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