Study: The Far-Reaching Implications of the ICD-10 Transition


"I just knew this would be a bigger problem than originally estimated."

So says Yves A. Lussier, MD, a professor of medicine and bioengineering at the University of Illinois at Chicago, the assistant vice president for health affairs at the University of Illinois Hospital & Health Sciences System and director of the Institute For Interventional Health Informatics, about the upcoming transition to ICD-10.

Figures from the American Medical Association and other groups underestimated the impact, financial and otherwise, of the transition by "only looking at technical, rather than strategic, changes" involved, says Dr. Lussier. He projects the results will go well beyond technical updates needed in the billing and coding department to affect strategic decisions made by administrators.

The impact of the ICD-10 transition will arise from a complicated relationship between current ICD-9 codes and their ICD-10 counterparts, as shown in a study led by Dr. Lussier and published in the Journal of American Medical Informatics Association.

Dr. Lussier's team used ICD-9 to ICD-10 data mapping files from CMS and general equivalence mappings to determine how ICD-9 billing codes would translate to ICD-10 codes. Five mapping categories were identified to describe the relationships between codes under both systems: identity, class-to-subclass, subclass-to-class, convoluted and no mapping.

The results showed 36 percent of mappings fell into the convoluted category, meaning no clear mapping from ICD-9 to ICD-10 exists, representing the most complicated and potentially misleading transitions. Dr. Lussier cites the example of the codes for abdominal pain. Under ICD-10, it must be specified which section of the abdomen is causing discomfort. "It may seem straightforward," says Dr. Lussier, but he says nurses and physicians know that in conditions like acute appendicitis, the pain moves to different parts of the abdomen. "As the patient moves though exams and intake, the pain keeps moving, but the disease is in the same area," he says. "But depending on the time the chart is written, it will say something different."

The study further shows these convoluted mappings are not distributed evenly among specialties. Results show specialties like hematology and oncology will have the easiest transitions to ICD-10, as only about 5 percent of the mappings for terms within these specialties were found to be convoluted. Convoluted mappings within obstetrics, psychiatry and emergency medicine hit 60 percent. However, most specialties will be at least somewhat affected — 42 percent of infectious disease code mappings will be convoluted, codes that will affect a broad spectrum of specialties, says Dr. Lussier..  

The transition will also add costs to a hospital's coding and billing department. These disparities between ICD-9 and ICD-10, including the larger number of codes in ICD-10 as compared with ICD-9, will force a costly change. "There will be a dramatic change in the [coding and billing] process," says Dr. Lussier. "Every small clinic or individual practice will have to contract it out, and larger organizations will have to hire additional people. Departments and specialties most impacted by the change will be orthopedics, rheumatology, emergency departments, psychiatry and gyneco-obstetrics, as these will see the number of codes used increase between five and fifteen times," he says. Some organizations may choose to not use the full number of codes in ICD-10 to simplify the transition, "but then they'll have to hire an attorney" to help protect against false claims allegations, says Dr. Lussier.

Additionally, Dr. Lussier stresses the implications of the ICD-10 transition will reach beyond a hospital's billing and coding department. "Physicians don't use billing codes to treat patients, so it won't immediately affect patient care," he says. However, senior hospital administrators often rely on these codes to get an understanding of conditions treated at the hospital and use the information to make strategic and financial decisions. The transition, Dr. Lussier warns, may reclassify patients in such a way as to show misleading patterns or sudden changes in patient population caused not by an actual change, but by a change in how conditions are coded.

To help providers anticipate where coding changes might arise within their organizations, Dr. Lussier and his team created an online tool that allows providers to enter specific codes and costs to gauge the transitions' impact on financial reporting.

"Using this tool, providers can see what the new normal will look like" under ICD-10 and help plan accordingly, says Dr. Lussier. Planning ahead will be necessary, as "it's going to be a very dramatic change," he says.  

More Articles on ICD-10:

CMS Updates ICD-10 General Equivalence Mappings
ICD-10 Codes That Matter
ICD-10: 3 Myths Debunked

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