ICD-10 Coding Switch: Short-term Headaches; Long-Term Benefits

On October 1, 2015, US healthcare providers will transition to the tenth version of ICD-10, the World Health Organization (WHO) disease classification system. Approved by WHO in 1990, ICD-10 is now used by more than 115 countries to record morbidity and mortality statistics, and more than 20 countries incorporate ICD-10 into their reimbursement processes. The US version, modified by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS), includes ICD-10 Clinical Modification (ICD-10-CM), comprising 68,000 codes for use in clinical settings, and the ICD-10 Procedure Coding System (ICD-10-PCS), comprising an additional 75,000 procedure codes.

Methods of disease classification developed in England and France in the 17th and 18th centuries remain the foundation for systems used today to classify morbidity and mortality (1). The United States adopted the World Health Organization (WHO) Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death in 1948. The ninth version of this manual (ICD-9) was approved by WHO in 1975, and a version modified for the American hospital system was adopted in 1979. In the US, providers use Current Procedural Terminology (CPT) codes, updated yearly by the American Medical Association, to document and bill for specific medical procedures and services. ICD-9 disease classifications began to be incorporated into claims processing in the 1980s.

Why switch?

Since the adoption of ICD-9 in 1979, an explosion of new technologies, new procedures, and new quality measures has produced more detail than can be supported by the current system and codes. Moreover, today’s healthcare is global, and it is becoming increasingly difficult to share data critical to public health and research when classification systems are out of sync. According to the American Health Information Management System, ICD-9 “can’t take healthcare into the future” (2).

Many experts speculate that the increased specificity of ICD-10 codes will reduce the need for repetitive exchanges between providers and insurance companies regarding claims, and ultimately reduce the incidence of rejected claims. In addition, large and small healthcare providers may be able to use the increased specificity such as the coding for underlying causes and co-morbidities, to improve patient outcomes and better allocate internal resources.

No pain, no gain?

Success of transitions to ICD-10 will depend on many organizations, not just providers: electronic health record (EHR) vendors, insurance companies, and others must also convert their systems. Worst-case scenarios for physician practices during the transition include slowed productivity, higher percentages of rejected claims, and short-term increases in unbilled receivables.

To support the transition, on June 6, 2015, CMS and AMA issued a joint statement highlighting efforts to help physicians make the switch (http://cms.gov/Medicare/Coding/ICD10/Downloads/AMA-CMS-press-release-letterhead-07-05-15.pdf). CMS and AMA will provide educational support before the transition; to address questions post-transition, CMS will set up a communications center and support an ICD-10 ombudsman, and for 12 months post-transition, CMS will allow flexibility in claims and quality reporting.

Many of the new codes relate to the musculoskeletal system, with significant expansions in coding fractures, so some areas of practice will experience more change than others. Nephrology is not anticipating the same level of change as orthopedics, but all coders, physicians, and insurance companies must learn the new chapter organization, new codes, and adapt to providing more, and different kinds of, documentation. Combination codes that include acuity or severity will impact nephrology coding, especially chronic kidney disease (CKD). Diseases closely associated with kidney disease, such as diabetes and hypertension, will add to the learning curve for kidney physicians and staff. Several of the resources listed below focus on the impact of the conversion to ICD-10 on nephrology.

Within and outside the clinic setting, the conversion to ICD-10 may require efforts not yet fully anticipated. The General Equivalence Mappings (GEM) that support the transition from ICD-9 coding to ICD-10 coding in the clinic and hospital settings may not provide comparability ratios for tracking longitudinal data (3). New ICD-10 codes must be incorporated into reporting of quality measures: for example, each AHRQ quality indicator technical specification with ICD-9 CM codes must be converted to ICD-10 CM/PCS codes. After October 1, challenges may arise when ICD-10 codes cannot be used: for instance, in the US, workers’ compensation and auto insurance claims are not required to incorporate ICD 10 coding.

While the headaches are predictable, the increased precision of these classifications, the improved integration with electronic health records, and the ability to convey more detailed data about patient outcomes, may prove great aids to nephrologists and others in their ongoing efforts to evolve and improve patient care.