Using ICD-10 to optimize patient care

FigureThe U.S. healthcare delivery system is currently experiencing one of its greatest administrative changes since Y2K: moving from the 9th edition of the International Classification of Diseases (ICD-9) to the 10th edition (ICD-10). Officially adopted for use by the international community in 1900, the ICD is the standard diagnostic tool used by countries across the globe for epidemiology, clinical use, and health management activities, including analysis of the general health situation of specific groups and population management.1 ICD codes are also used to monitor the prevalence of known diseases and introduction of new diseases, such as the 2014 Ebola outbreak and the identification of Legionnaires' disease in 1976. The use of ICD codes on legal documents, such as health records or death certificates, allows for an organized way to share and retrieve diagnostic information for clinical, epidemiological, and quality purposes, and provides the foundation for compiling and tracking national mortality and morbidity. In addition, many countries, including Australia, Belgium, Canada, France, Germany, the United Kingdom, and the United States, use the ICD to determine reimbursement or case mixes.2 When the ICD was originally adopted, it was agreed that that the codes would be reviewed and updated once every 10 years to reflect medical advancements and identification of new diseases. Coordination of this activity became the responsibility of the World Health Organization (WHO) in 1948. Although participants in the process have been relatively faithful to the 10-year schedule, countries have followed their own timelines for implementing each new version. For example, ICD-10 was released by the WHO for adoption in 1993. The Czech Republic was the first to adopt it 1 year later, followed by the United Kingdom in 1995, Sweden in 1997, and Australia in 1998. By 2008, most European countries had made the transition from ICD-9 to ICD-10.3 Twenty-two years after its release, the United States is the last participating country to adopt ICD-10. ICD-10 goes live this month—how will it affect you, your staff, and your patients? Changes, in brief Reasons for the delay are numerous, but the greatest contributing factor is the complexity of changes made between ICD-9 and ICD-10. In addition to adding codes that acknowledge medical advancements and the introduction of new diseases, ICD-10 has been expanded to include greater specificity and granularity of detail related to diagnosis and treatment. In a fact sheet published by the American Medical Association (AMA) in October 2014, the value of the additional information was explained this way: “If a patient is seen for treatment of a burn on the right arm, the ICD-9 diagnosis code doesn't distinguish that the burn is on the right arm. If the patient is seen a few weeks later for another burn on the left arm, the same ICD-9 diagnosis code would be reported. Additional documentation would likely be required for a claim for the treatment to explain that the burn treated at this time is a different burn from the one that was treated previously. In the ICD-10 diagnosis code set, characters in the code identify right versus left, initial encounter versus subsequent encounter, and other clinical information.”4 It has now been 35 years since ICD-9 was implemented and some of the chapters are full, which means that no new codes may be added to them. As a work-around, new treatments or diagnoses that would normally be included in one chapter have been inserted into a different chapter that's deemed to be the most closely associated with the full chapter and has available codes. This makes it difficult to gather all of the pertinent information for reporting and tracking purposes. To accommodate the additional functionality, the structure of the ICD codes has been changed. ICD-9 codes have three to five characters. The first digit may be alpha or numeric; all remaining characters are numeric. ICD-10 codes have three to seven characters. The first digit is alpha, digits two and three are numeric, and all remaining digits may be alpha or numeric. The end result is that we go from approximately 13,000 diagnostic codes under ICD-9 to more than 68,000 under ICD-10, and from 3,800 procedure codes under ICD-9 to nearly 72,000 under ICD-10. Because the structure is so completely different and there's so much more information contained in the ICD-10 codes, there are few direct crosswalks between ICD-9 and ICD-10. In fact, less than 25% of existing ICD-9 codes have a direct correlation to ICD-10 codes.5 The additional detail provided by ICD-10 means that one ICD-9 code may be replaced by any one of a number of ICD-10 codes, depending on laterality, episode of care, comorbidities, and so on. Further complicating matters, ICD-10 is the first revision of the codes being made in an electronic environment. In all previous implementations, business processes affected by the change were almost completely manual; implementing the changes involved revising your documentation and educating your affected workforce. Implementation of ICD-10 has required remediation of every health information technology system touched by an ICD-10 code, including electronic medical records, accounting systems, and systems that accumulate information for and produce reports—a remediation effort that, in many instances, has required building a completely new flow of information. And because every code has a chance of being used, many systems can't be remediated using a subset of the codes; instead, the entire group of new codes has to be incorporated. What does it mean for your staff? For the majority of those in the nursing profession, the most obvious impact of ICD-10 relates to documentation. Much has been written about the importance of more detailed documentation under ICD-10 to ensure proper coding for billing purposes and assist in continuity of care between multiple providers involved in a single episode of care. The example cited previously from the AMA does an excellent job of illustrating the impact that documentation will have on these areas. The documentation required for a patient presenting with evidence of a stroke drives the point home even further. Under ICD-9, the only information captured was that the patient had a stroke. Under ICD-10, in order for the coder to code appropriately, the healthcare provider will need to indicate the location of the stroke: whether it occurred in the right, left, middle, interior, or posterior of the cerebral artery. This not only helps with coding, it also impacts the quality of care that the patient will receive should he or she have another stroke. The healthcare team will be able to more effectively determine the impact of the second stroke, such as whether it affected a new area of the brain or exacerbated the impact of the first stroke on the same area. The point has also been made that this same level of detail is equally beneficial under ICD-9, so those who have used the additional implementation time to improve documentation habits are well positioned for the transition. Nurses who work in smaller practices where they have a broader scope of responsibilities with duties extending into analytics, however, may find more of their day-to-day activities affected by the change. Healthcare organizations use analytics for a variety of internal and external purposes. Internal business purposes may include the use of information associated with diagnostic and/or procedures codes to manage budgets and personnel resources, or identify the impact of case mix on the overall business. Externally, this same information may be used to generate reports demonstrating regulatory compliance, achieve accreditation status, show impacts on population health initiatives, report into specialty society databases, and validate performance for reimbursement purposes. More advanced organizations use healthcare analytics to establish and track performance-based metrics, understand clinical outcomes, improve adherence to clinical guidelines, and improve patient care through the application of evidence-based medicine. In all of these instances, the goal is to produce consistent, accurate, and reliable information. Transitioning to ICD-10, analysts will need to find a way to mitigate the impact of the following challenges: For inpatient services, diagnosis and procedure codes are often grouped in diagnosis-related groups for claims and payment purposes; the grouping of codes will be different under ICD-10. A majority of individual ICD-9 diagnostic codes can map to any one of multiple ICD-10 diagnostic codes. A majority of individual ICD-9 procedural codes can map to any one of multiple ICD-10 procedural codes. The analytics being tracked may involve episodes of care that began before October 1, 2015, and aren't resolved until after October 1, 2015, meaning that patient information will be documented using both versions of the ICD, but will need to align to provide a consistent picture of the patient, his or her progress, and the healthcare outcome. Matters may be further complicated by the sharing of information across different organizational units and fragmented applications. It will take some time for the new codes to be “normalized” and for the industry to develop commonly used codes for the same or similar circumstances. This will also be true for individual organizations. During the initial implementation of ICD-10, one physician or unit of a healthcare system may translate an ICD-9 code into a specific ICD-10 code, whereas another physician or unit involved in that same episode of care may translate it differently. Analysts who use this information for tracking and generating reports will need to find a way to tease out these details to create the most accurate information possible for reporting purposes. Are you prepared? By now, analytics departments should've run dummy reports using ICD-10 codes and cross-checking the results against ICD-9 coded reports to identify and correct for differences between the two that may affect decision making. For example, the granularity of detail provided under ICD-10 may lead to the identification of individuals to be included in disease management reports that may have been previously overlooked using ICD-9 codes. Similarly, the additional detail provided under ICD-10 may help determine that other individuals who had previously been included in a disease management category under ICD-9 shouldn't be included. Identifying these situations and adjusting for them allows organizations to create more accurate baseline reports and decrease the potential for disruptions. Those of you whose duties include greater involvement in day-to-day office administration may need to pay more attention to the overall implementation efforts of your organization. The Healthcare Information and Management Systems Society has prepared a last-minute checklist (www.himss.org/library/icd-10/playbook) to assist you in ensuring that all critical activities have been addressed. Chief among these activities is testing. If your organization uses the services of a third-party vendor or clearinghouse, you should confirm with them that they've conducted testing with your payers. It may not be too late to ask if they'll demonstrate their level of confidence by agreeing to a performance guarantee related to ICD-10 readiness. If your organization prepares and submits its own claims, you should've already conducted your own testing. Beyond testing, other critical activities include ensuring that all applicable operating procedure documentation has been updated to reflect the change to ICD-10, pended and rejected claims volumes have been reduced as much as possible, baseline reports were created for use in monitoring these activities post go live, and procedures for monitoring pended and rejected claims status and revenue after the go live date have be established, along with agreed-upon procedures for addressing any unexpected spikes in activity. Organizations should also have reviewed any standing orders or previous authorizations impacting services scheduled to occur after October 1, 2015. Check with each of your commercial carriers to determine the approach they expect you to take to ensure continuity of care for your patients and uninterrupted revenue for your organization. Finally, if you've completed all of these activities, consider reviewing your billing history regarding the use of unspecified codes. Where possible, encourage your providers to expand their documentation to allow coders to use specific codes for billing. Organizations that have gone through this exercise report substantial increases in revenue under the current ICD-9 coding and anticipate fewer disruptions to their revenue streams under ICD-10. Whether your organization has completed its preparations for the transition to ICD-10 or not, no organization will be reimbursed for claims submitted for dates of service that occur on or after October 1, 2015, unless those claims are coded using ICD-10. If your organization has done nothing to prepare and you're concerned that you won't be able to submit claims using ICD-10 codes, don't panic. There are resources available to help you get past this hurdle. A Google search will return information on a variety of commercial vendor solutions, including some that are cloud-based and touted as being easy to install and use. The Centers for Medicare and Medicaid Services (CMS) is offering free billing software through every Medicare administrative contractor (MAC) across the nation and some MACs are allowing Part B Medicare claims to be submitted through their provider portals. As a final alternative, organizations that qualify for an administrative simplification act waiver may be able to submit paper claims to the CMS. Most commercial carriers will also accept properly coded paper claims, but they must be submitted using the most current claims submission forms. Transition time The transition to ICD-10 has been a long time coming. The lack of a straight crosswalk from ICD-9 to ICD-10, substantial increases in the number of available codes, and the need for more complete and comprehensive documentation to support the choice of codes used has created a tremendous amount of anxiety, especially as it relates to the potential impact on provider revenue. Numerous delays have allowed the industry the additional time needed to complete system remediation, update standard operating procedures, improve documentation, educate providers and coders, conduct preproduction testing, and develop mitigation strategies to get organizations through short-term increases in pended or rejected claims volumes and the associated disruptions to revenue streams. The better prepared your organization is for this change, the better the quality of care you'll be able to provide your patients and the fewer disruptions your staff and your patients will experience.

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