ICD-10 Is Coming
ICD-10 is coming,
and savvy HIM professionals should begin to prepare now. The good news is that
while this new coding and classification
system will present a
challenge to those
the field, the result should be an
in medical record
With all the demands currently being placed upon health care entities, including year 2000 compliance and Health Insurance Portability and Accountability Act (HIPAA) implementation, there is quite enough work to keep everyone busy until well after 2000. However, there’s one more thing health information management (HIM) professionals should prepare for–the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and the ICD-10 Procedure Coding System (ICD-10-PCS). Although current coding systems will most likely remain in place through the year 2000, HIM professionals should prepare for these coding changes and build in enough system flexibility to allow for their use.
Status of ICD-10-CM
At a recent meeting of the ICD-9-CM Coordination and Maintenance Committee, a representative from the National Center for Health Statistics (NCHS) stated the Tabular List, Alphabetic Index and training manual for ICD-10-CM is expected to be completed by spring. Public comments received on the Tabular List (released winter 1998) are undergoing review, and further revisions are expected based on those comments. ICD-10-CM will be published in both book format and on CD-ROM.
The Health Care Financing Administra-tion’s (HCFA) ICD-10-PCS system has undergone formal independent review and testing by the Clinical Data Abstraction Centers. Further testing of the system is being performed using ambulatory records. ICD-10-PCS, including revisions made as a result of testing and clinical comments made by physician specialty groups, is expected to be available by the end of April.
It is important to note that the implementation of both ICD-10-CM and ICD-10-PCS is tied to HIPAA. Standards specified under certain provisions of HIPAA include those for code sets, defined as “any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes or medical procedural codes.” Code sets for medical data are required for administrative and financial health care transaction standards relating to diagnoses, procedures and drugs.
A Notice of Proposed Rule Making (NPRM) was published in the Federal Register on May 7, 1998. The code sets proposed as initial HIPAA standards are those already in use by most health plans, health care clearinghouses and health care pro-viders. These include ICD-9-CM, CPT-4, al-phanumeric HCPCS, Current Dental Ter-minology (CDT) and National Drug Codes (NDC).
According to regulators, although ICD-9-CM has weaknesses, there are no viable alternatives for the year 2000, when the electronic transmission standard is supposed to be in place. The agency also noted that many problems cannot be solved within the ICD-9-CM structure, but are being addressed in the next revision of ICD codes (ICD-10-CM for diagnoses and ICD-10-PCS for procedures). These coding systems are expected to be ready for implementation after the year 2000.
However, in its recommendations to the Secretary of Health and Human Services (HHS), the National Committee for Vital and Health Statistics (NCVHS)–which is the statutory federal advisory body to HHS on health data, standards, privacy and health information policy–asked that the industry be advised, “to build and modify their information systems to accommodate a change to ICD-10-CM diagnosis coding in the year 2001 and a major change to a unified approach to coding procedure (yet to be defined) by the year 2002 or 2003.”
The differences between the current coding system and its next revision include structural changes, organizational revisions and new features.
Comparing the ICD-9-CM diagnosis portion to the ICD-10-CM reveals some changes but also familiar territory. Structural revisions include a completely alphanumeric format, codes of up to six characters, and complete descriptions for each code. The classification of factors influencing health status and contact with health services and external causes of injury and poisoning in ICD-9-CM are no longer considered supplemental classifications in ICD-10-CM.
Organizational changes in ICD-10-CM include separating the sense organs from the diseases of the nervous system, rearranging the order of chapters and revising chapter titles. Also, some conditions have been moved into different chapters in the new version.
New features in ICD-10-CM include:
* The institution of combination codes for both symptom and diagnosis and etiology and manifestations;
* The expansion of many of ICD-10’s codes for laterality;
* The inclusion of complications following procedures in the chapter specific to the body system where the procedure took place; and
* The inclusion of the patient’s trimester in the obstetrics chapter.
When contrasting ICD-9-CM’s procedure portion to ICD-10-PCS, the latter system’s classification of procedures is very different than the current system. ICD-10-PCS contains:
* A seven-character, alphanumeric code in which each character has up to 34 different values;
* A code for every procedure;
* No diagnosis information within the code; and
* No eponyms.
The tabular portion of ICD-10-PCS is structured as a table. The first three characters of any given code are listed at the top; and valid fourth, fifth, sixth and seventh character choices are listed below. Organi-zationally, there are still 16 sections–however, it is not at all similar to ICD-9-CM’s 16 chapters based on body sys- tem. For example, ICD-10-PCS has specific sections for imaging, laboratory and mental heath. One new feature includes standardized terminology (i.e., there are no multiple meanings for the same term).
Impact on Data Collection
The transition to the next generation of ICD-10 is going to affect both the collection of health care data and the jobs of those who record such information. Not only will HIM professionals require additional education and training on the specifics of what and how data should be recorded, but they also may need more time to complete coding tasks. Recorders of health care data must know the new and revised documentation requirements (such as new definitions) and be educated on the information needed for a code to be identified. The result will be an overall improvement in medical record documentation.
While both ICD-10-CM and ICD-10-PCS offer more code choices, they also require greater documentation requirements on the part of the health care provider and greater knowledge on the part of the coder. For example, to choose a specific code for a decubitus ulcer from ICD-10-CM, the medical record must contain the severity of the decubitus ulcer (see Table 1).
As for the impact on those who perform the coding, a higher degree of clinical knowledge may be necessary. How coding is done also may change. For example, testing of ICD-10-PCS by the Clinical Data Abstraction Centers resulted in a recommendation that it would not be incorrect to code using just the Tabular List. Coders must understand the requirements for both systems and be educated on the information needed for a code to be identified.
The coder will need to learn how diseases and procedures that were classified one way in ICD-9-CM are classified differently in ICD-10-CM and ICD-10-PCS. For example, in ICD-10-PCS, the coder must understand terms like transorifice, intraluminal and endoscopic, and he or she must be able to find and translate words that indicate these approaches in the medical record (see Table 2).
Impact on Data Integrity
As with any new system, a learning curve exists and mistakes will be made while people are adjusting. While HIM professionals may have less of a challenge on the diagnosis side (because ICD-9-CM and ICD-10-CM share many similarities), there still are major differences to be understood for accurate coding to occur.
The more formidable task in ensuring data integrity, however, will come from the transition to ICD-10-PCS, as this system differs vastly from ICD-9-CM. Those who document in the medical record and those who code such information will need to learn a whole new classification process.
Problems should be anticipated when transitioning to ICD-10-CM and ICD-10-PCS. Both the quantity and quality of health care data will be affected. Although there might be less reliable, and, at times, confusing data during the transition, ultimately more and better information will result. Still, caution must be exercised when interpreting data, as diagnoses and procedures will be classified differently. In some cases, the number of codes may increase or decrease (see Table 3).
This, of course, also will impact data comparisons. HIM professionals will have to take this into account when performing analyses that span a time period when both systems (ICD-9-CM and ICD-10-CM/ICD-10-PCS) were being used to code data–i.e., if comparing data from the last two years, but ICD-10 has only been used for one.
While no decisions have been made regarding the changes in code set standards (as recommended in the May 1998 Federal Register), it is certain that there will be changes to coding and classification standards because of the international adoption of ICD-10.
In addition, recommendations for changes after the year 2000 will most definitely wait until these new systems, ICD-10-CM and ICD-10-PCS, have been thoroughly tested and further discussions occur regarding the options for moving toward a more integrated approach to procedure coding. *
Kathy Brouch is a part-time employee of HCIA in Ann Arbor, MI, and an independent consultant. She has more than 20 years’ experience in HIM.
By Kathy Brouch, RRA, CCS
|707.0 Decubitus ulcer|
|L89.0 Decubitus ulcer limited to breakdown of the skin|
|L89.1 Decubitus ulcer with fat layer exposed|
|L89.2 Decubitus ulcer with necrosis of muscle|
|L89.3 Decubitus ulcer with necrosis of bone|
|L89.9 Decubitus ulcer without mention of severity|
|60.11 Closed [percutaneous] [needle] biopsy of prostate|
|60.12 Open biopsy of prostate|
|0WB00ZX Diagnostic excision of prostate, open|
|0WB03ZX Diagnostic excision of prostate, percutaneous|
|0WB04ZX Diagnostic excision of prostate, percutaneous, endoscopic|
|0WB07ZX Diagnostic excision of prostate, transorifice intraluminal|
|0WB08ZX Diagnostic excision of prostate, transorifice intraluminal endoscopic|
|414.00 Atherosclerotic heart disease of unspecified type of vessel, native or graft|
|411.1 Unstable angina|
|I25.12 Atherosclerotic heart disease with unstable angina|