mentation first came as U.S. health care agencies worked to develop modifica- tions to ICD-10 specifically for use in this country. Two separate ICD-10 code sets were developed for the United States. The Centers for Disease Control and Preven- tion developed the ICD-10 Clinical Modi- fications, or ICD-10-CM, as the diagnos- tic classification system for use in all U.S. health care treatment settings. The U.S. Centers for Medicare & Medicaid Ser- vices (CMS) developed the ICD-10 Pro- cedural Coding System (ICD-10-PCS) for inpatient hospital settings only. Other delays have occurred for politi-
cal reasons, most recently in 2009 when CMS pushed back the implementation deadline from Oct. 1, 2011, to Oct. 1, 2013, because of concerns expressed by physicians, hospitals, and others about the cost and complexity of adjusting to the new coding system. According to a January 2009 Wall
Street Journal article, CMS received more than 3,000 comments to its ICD- 10 proposal at that time. Many of those comments requested more time to com- ply because of the cost and the need for training and testing of new billing and coding systems.
Growing exponentially Experts say the switch to ICD-10 was necessary to accommodate new medical conditions. ICD-9 has essentially run out of available codes for those new condi- tions, they say. “They don’t have any more room to
add any more diagnosis codes in ICD- 9,” Ms. Davis said. “So as new medical conditions develop, a lot of those get dumped into the unspecified diagno- sis code category in ICD-9. ICD-10 has room to grow.” ICD-9-CM has only some 14,000 codes, while ICD-10 has more than 68,000 codes, says Ms. Davis. In some instances, the number of potential codes that could be used for the same diagno- sis has increased exponentially. For example, CMS says there are nine potential location codes for pressure ul- cers under ICD-9-CM, while ICD-10-CM has some 125 codes. The ICD-9 codes
30 TEXAS MEDICINE February 2012
show broad location but not depth, whereas the ICD-10 codes show specific location as well as depth. Not only are their more codes under
ICD-10, but also there are more digits for each code. ICD-9 codes have fewer digits and are strictly numeric. ICD-10 codes, on the other hand, have up to seven digits and can be both letters and numerals, Ms. Davis says. For instance, the ICD-9 code for infec- tion or inflammation of the middle ear is 381.01, while the basic code for the same condition under ICD-10 is H65.00. Under ICD-10, however, there could be up to six different codes for an ear infec- tion indicating whether the infection is in the right or left ear or bilateral and whether it is a recurrent condition. Cod- ers also are instructed to use an addi- tional code to identify exposure to envi- ronmental tobacco smoke, history of to- bacco use, and other various conditions. Experts say the learning curve likely will be steep for both coders and physi- cians who will have to learn an entirely new set of codes. “A successful and smooth transition over to ICD-10 will need to include education, awareness of the continual changes, and strong communication throughout the entire practice,” said Ms. Bettridge.
Ms. Davis says many specialists who see patients with the same condition throughout the day know “off the top of their heads” the most frequent codes they bill. Memorizing the new code set won’t be as easy because of the sheer number of codes and the use of both let- ters and numerals. Dr. Spain adds that many physicians use a super bill or cheat sheet that has a list of their most commonly used codes.
“When you’re picking out of 50 or maybe 100, that’s pretty easy to do, but now that your code set is going to be expand- ed, there’s just no way you can put 1,500 codes on a claim form or the back side of your super bill.” Dr. Spain, who is a member of the AAPC National Advisory Board, says physicians are going to have to be much more conscientious in their documenta- tion in order for their coders to be able
to select the correct codes under ICD-10. “In ICD-9, we have 30 different codes
for forearm fracture,” he said. “In ICD- 10, there are more than 100 possible codes for just a fractured ulna. So it’s going to take office people more time to look at the documentation to make sure they’re coding it properly. And there’s going to be more burden on physicians to be sure that they have all that infor- mation in their notes.” Because of that, physicians can’t just simply document a fracture anymore. They will have to specify whether the encounter is an initial or subsequent visit and could also need to document whether the fracture represents a mal- union, delayed union, nonunion, or normal healing. Similar requirements for additional information are necessary for the proper coding of countless other diagnoses.
Nancy Spector, MS, director of elec-
tronic medical systems for AMA, says physicians need to analyze their practic- es and identify every way they use ICD-9 coding. All of those areas will have to transition to ICD-10. “This is one that’s really going to touch on everything that the practice is doing, and that means clinical pieces, not just administrative pieces.”
Where’s the price tag? In a March 2004 report, the RAND Corp. concluded that ICD-10-CM and ICD-10- PCS were technically superior to ICD-9- CM. “If nothing else, they represent the state of knowledge of the 1990s rather than of the 1970s,” the report stated. “They have also been deemed more logi- cally organized, and they are unques- tionably more detailed — by a factor of two in diagnoses (and 20 for injuries) and by a factor of 50 in procedures.” Despite its benefits, implementation
of ICD-10 is not without substantial cost for physicians, hospitals, health plans, other clinicians, and the government. In its report, RAND said the costs fall into three categories: training, productivity losses, and system changes. RAND estimated the total cost of ICD- 10 implementation at between $425 mil- lion and $1.15 billion in one-time costs,
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