ICD-10 or ICD-11? The Dilemma Behind Both Coding Systems

When it comes to ICD-10 and ICD-11, there are generally two camps. There are those that believe ICD-10 is a necessary coding step to take, and all hospitals and providers should make the steady progress toward its adoption. There are also those that believe ICD-10 should be skipped for ICD-11, which the rest of the world is preparing for.

Generally, all camps can agree on one thing: ICD-9 desperately needs an upgrade. "ICD-9 is archaic," says Jon Elion, MD, an associate professor of medicine at Brown University, a part-time cardiologist at The Miriam Hospital in Providence, R.I., and founder of clinical documentation improvement company ChartWise Medical Systems. "There are pages of tuberculosis codes, but there's only one HIV code. It hasn't kept up with modern diagnoses and procedures — it's just grossly out-of-date."

Dr. Elion says there are pros and cons of both ICD-10 and ICD-11, and their impacts on hospitals will both be significant. However, he argues the debate is more than just ICD-10 versus ICD-11 — the healthcare community should be working together to figure out how to make coding system transitions smoother in the future and to write better ICD programs from the onset.

Perspective of ICD-10

ICD-10 was first released on a global scale in 1993. However, the United States needed to make its own clinical modification version, or ICD-10-CM. After several years of modifying the coding system to describe morbidity, ICD-10-CM was finally finished in 2003. While the United States does not use ICD-10 currently for hospitals and provider billing, it actually does use ICD-10 on the world level to report mortality data.

HHS recently proposed to change the new go-live date of ICD-10 from Oct. 1, 2013, to Oct. 1, 2014. While Dr. Elion admits that it is a major dilemma to be using a coding system that is one release behind the rest of the world, there are some beneficial aspects to ICD-10. For example, he says the specificity of ICD-10 is actually a positive and the outcry of there being too many codes is inflated, at least from a physician point of view.

Dr. Elion says ICD-10 allots for more codes, and this is a good thing because it will finally allow providers to write down all pertinent medical information that they tracked anyway. For example, in ICD-9, a physician notes how a patient has a fracture of the femur, end of story. In ICD-10, a physician would note if it's the right or left femur, whether it was the patient's first office visit, is it displaced, is it healing, etc.

"The explosion in number of codes is highly overrated," Dr. Elion says. "[The new code sets] are all things we keep track of. Many of the new codes are due to having to specify whether something is on the left or the right. Coders have more to worry about, but it's not that many new medical concepts."

However, in a recent article in Health Affairs, five leading medical informatics experts and physicians agreed that ICD-10 is a major upgrade over ICD-9, but they countered that the "base knowledge structures" of ICD-10 do not reflect what healthcare has learned in the 21st century. For example, the authors said ICD-10 does not use any genomic information.

Perspective of ICD-11

The same Health Affairs authors said healthcare should be preparing for ICD-11 and the Systematized Nomenclature of Medicine-Clinical Terms, or SNOMED, as ICD-10 becomes the norm. The World Health Organization is preparing to launch the first version of ICD-11 within a few years.  

Dr. Elion agrees that ICD-11 has a mountain of positives because it is "medical-focused" and physicians were involved in the development of every portion. He adds that critics of ICD-11 argue the ICD-11-CM version will take just as long as ICD-10-CM, but he believes ICD-11 will go through a more efficient adaptation process. "People say ICD-10 took 10 years to develop clinical modifications, and therefore ICD-11 is going to take just as long. I don't think it will," Dr. Elion says. "There are a lot of politics and learning in those 10 years that will not need to be repeated."

However, many ICD-10 proponents believe skipping ICD-10 would be like skipping a necessary prerequisite for a master's course. Hospitals, providers, coders and all other healthcare professionals could be missing out on necessary coding education.

The true dilemma and solution?

The biggest problem in this debate, says Dr. Elion, isn't whether healthcare should go to ICD-10 or ICD-11. The dilemma is that the healthcare community is not writing the coding systems and coding programs with the right mindset. The software that supports ICD-10, ICD-11 and every other medical classification of diseases and procedures in the future must be designed in a way that allows for easier transitions to the next classification, he says.

Dr. Elion points to the American Medical Association, which recently advocated for a two-year delay of ICD-10. The AMA did not recommend waiting until ICD-11, but it did recommend that a study be conducted to see the potential value of ICD-10 and ICD-11. Dr. Elion says software vendors and other key stakeholders in the ICD community should be proactive in this current environment and create medical classification software that will work for the present and future.

"There needs to be a realization to software vendors that there's going to be ICD-12 and 13. We need to stop writing archaic software," Dr. Elion says. "We talk about these things: Is this '1 of 1' or '1 of n'? Is this the one and only way we're going to see things? Or is this the first instance of some type of general pattern? People have to stop writing software that is so locked into a given ICD code set."

More Articles on ICD-10:

5 Components of a Hospital's ICD-10 Impact Assessment

Podcast: How Should Hospitals Prepare for ICD-10?

In the Fog of Delay: What's Next for ICD-10?

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