The International Classification of Diseases tool is a century-old classification system used to code for diseases, injuries and symptoms in a clinical setting, currently in its tenth iteration. Minor updates occur yearly with major revisions every ten years. Although ICD-9 is thirty years old, it is still widely used in the United States. The transition to ICD-10 is required in the U.S. by October 2014, over a decade after its development.
From a clinician’s perspective using an EHR, the ICD codes are transparent. A physician doesn’t select “I21.x” (ICD-10) or 410 (ICD-9) for myocardial infarction. The computer system allows natural language documentation linked in the background to the codified diagnoses. The benefit is that where ICD-9 has a single code mapped to “acute myocardial infarction,” ICD-10 has a category for myocardial infarction with six sub-items allowing for greater flexibility.
This expansion of subcategories is seen throughout a comparison of these two versions due to the scope of the changes made. There are approximately five times the number of codes in ICD-10 as compared to ICD-9, many of them aimed at identifying the location. This greatly increased specificity allows for more precise billing and coding.
The challenge for many clinics and hospitals is the cost of transitioning to a new system. Not only is there a cost for the new product and its implementation, many facilities use a billing system that is separate from their documentation system, leading to a more complex upgrade. Both the EHR and billing systems and the interface must be adapted and tested.
The greatest challenge will likely be retraining staff that has been using the same processes and codes for two decades. Where a coder could previously complete his or her work without any reference materials, the new workflow will require training and time to return staff to their previous proficiency and efficiency. Current Procedural Terminology codes are not affected for outpatients, but a completely new inpatient procedure billing process, ICD-10-PCS, comes with ICD-10 adoption.
Despite the challenges, there are benefits to the transition that transcends the government requirement. The alphanumeric structure of ICD-10 and increased character length allows greater flexibility for the addition new codes as they are needed. ICD-9’s lack of flexibility has forced many facilities to bill under invalid codes because no such code exists for the patient’s actual diagnosis, or the diagnosis code is a repeated due to a similar injury or illness.
For example, if the patient has a wound on her left arm and then returns a week later with a wound on her right arm, ICD-9 uses the same code, which confuses coding and some EHRs. By comparison, ICD-10 allows for two distinct codes to be used for clarity because laterality is built into the classification system.
An additional benefit is the associated procedure codes. Where ICD-9 has only a few thousand of these codes, ICD-10 provides almost 90,000. This is likely the greatest benefit to the billing teams. The ICD-9 terminology is thirty years old with virtually no associated procedural updates due to the lack of flexibility. The majority of surgical interventions, cancer treatments and wound care equipment simply did not exist when ICD-9 was coded and could not be properly documented within its classification. ICD-10 contains current medical procedures as well as allowing for future additions.
Although the transition is fast approaching, ICD-10 is not the end for clinicians. ICD-11 is currently in testing with an official release in 2015. Many debate whether it would be better to delay and transition directly to ICD-11. Proponents of the ICD-10 transition indicate that it is a stepping stone to the eventual adoption of ICD-11. Just as it is much easier to transition from Windows 7 to Windows 8 than from XP to Windows 8 due to the incremental changes, so is it with ICD-9, -10, and -11.
Regardless of benefits, costs or biases surrounding the ICD classifications, the requirement is in place, and it has been made clear that the date will not move again. ICD-9 will no longer be accepted by payers beginning October 2014, so transition is unavoidable. ICD-11 will not be available by October 2014, meaning its adoption is not an option within the requirement timeframe.
The ICD-10 transition will be a project unto itself with a national big bang implementation on October 1, 2014. Larger organizations will be more greatly impacted due to larger staff size and greater patient loads. Early involvement, planning and testing will make the transition smoother for providers and payers alike. Given the challenges and benefits of transitioning to the next level of code, let’s aim to pursue ICD-11 before ICD-12 is on the horizon.
MedSys Group Consultant, Sarah E. Fletcher, BS, BSN, RN-BC has worked in technology for over fifteen years. The last seven years have been within the nursing profession, beginning in critical care and transitioning quickly to nursing informatics. She is a certified nurse informaticist and manages a regular informatics certification series for students seeking ANCC certification in nursing informatics. She currently works with MedSys Group Consulting supporting a multi-hospital system.
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