ICD-10
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Even More Numbers to Remember

We all learned about the importance of numbers back in Kindergarten.  As we progressed through the education system we learned numbers can be used to build buildings or calculate dosages by body weight.  If you have listened to your billing staff or get involved in any claims processing for payment of your professional services, you realize that to get paid we jam the claim with numbers.  The whole payment system is ‘code dependent’ — no numbers, no money.  Some numbers say what you did and others tell why you did it.

A huge change is being considered in the code set that communicates the why, the diagnostic code set.  Some folks want us to use a whole new system called ICD-10 (International Classification of Diseases, 10^th edition) and get rid of the ICD-9-CM (International Classification of Diseases, 9^th edition, Clinical Modification).  The 3 to 5 digit numbers you see on your current forms are the ICD-9-CM numbers.  On the face of it, this change doesn’t seem to mean much to the clinician.  Other than a change to the numbers on the encounter forms or charge tickets used to identify diagnosis to the business office, not much appears to change.  So why care?  Isn’t this a just billing thing or something that really only concerns academics and statisticians?   Well, No!  The change has a very large impact on the quality, costs and documentation needs of health care.

A switch from ICD-9-CM (I-9) to I-10 will be a very big change.  Over 2 billion encounters per year occur in Hospitals and Medical offices that must be coded.  And that only accounts for the clinical picture.  In addition, the entire Healthcare system from quality of care, to medical records, to incentive salary systems, to reimbursement will need to adapt.  I-9 contains about 13,000 3-5 digit codes (the ones you use now).  I-10 would expand the possibilities to over 120,000 3-7 digit codes.  That translates as a need for clinicians to document additional details that have little impact on clinical necessity.

To see the whole issue, one must consider who benefits and who implements the new system.  Within the Department of Health and Human Services (which is responsible for the diagnostic code system) , the proposed change is managed by the National Committee on Vital and Health Statistics.  So, one can fairly conclude that real benefit is to statistical researchers.  If one looks at the testimony in support of I-10, that conclusion seems valid.  3 M Corporation has the contracts to deal with the creation of a new system and put together software to support it.  So they are all for I-10.  Professional coding organizations have also endorsed the new system.  One should note, none of the above are clinicians and all have a certain self interest that is served by the proposed change.

By now, you may have guessed that I-10 does not strike me as a real benefit to the healthcare system.  Nevertheless, I will try to summarize the opposing positions as objectively as possible.  On the pro side, the arguments run as follows: I-10 is much more accurate.  Using it means that Hospitals can report the exact artery and surgical approach used.  That means the payors can provide a more accurate payment for each procedure and the exact overhead costs involved.  Pro folks also say that the training necessary to change to I-10 will be easily implemented.  Funds that hospitals and Clinics have set in current budgets for training will just be used in another way.  Besides International treaties call for the US to share information with the rest of the world using WHO’s systems.  Also, I-10 will help standardize terminology.  Finally, we update our computer systems all the time so new programming won’t cost too much.

The con side holds that the pro side is not thinking things through.  The cons see the idea as another case of ‘I’m from DC and I’m here to help you.’ Accuracy due to I-10 requirements of detail means more documentation that probably is of no real benefit to clinicians.  Somehow clinicians always seem to lose money every time the system is ‘improved.’ Do you really want to spend more time to get clinical documentation in great detail just so someone can assign a code?  I-10 will require documentation to the n^th degree.  For example, one I-10 code is used only when a patient has an open skull fracture and: open fractures of facial bones, 3 different types of intracranial hemorrhage, is unconscious for 24 hours and does not regain consciousness.  Now, that seems to me like over kill in the detail and from a billing perspective means delay in sending claims and receiving payment.  Another accuracy problem comes from the confusion of 1 vs. I and O vs. 0.  We learned that these characters cause errors but I-10 uses these characters.  What kind of data reliability are we going to get?

Now look at training costs.  Sure money meant to improve expertise can be used to retrain.  A couple of thoughts though: smaller hospitals and small practices may not have any money even for improving individual expertise.  Who pays for the retraining and what other things are not done because there is no money.  Over a half million coders will need retraining nor to mention clinicians.  And, while it is true that International Treaty says we need to share information that sharing is already being done from death records by the government Vital Statistics offices.

Then comes the idea I-10 will deal with terminology.  Sure, even I-9 has a problem with this.  The category 401, hypertension, is divided into malign, benign and unspecified.  Malign/benign are not a generally used terms in the US and unspecified tends not to be paid.  I-10 will add a large number of these terminology issues.  I-10 isn’t going to help.  Terminology standardization is better handled by other systems.

The final issue seems to be updating the computers.  No one has a good answer for who is going to pay for the new programming software.  Our experience from implementing the HIPAA rules on privacy shows that this will cost much more than simple updates.  That doesn’t even address the need for the complete rebuild of the DRG, APG and other reimbursement systems.  Nor are the costs of running both I-9 and I-10 until everyone gets transferred to I-10 being considered.

There is a lot to be said for implementing I-10.  Trouble is there is a great deal to be said for getting some better answers to potential problems.  Telling us the benefits outweigh the costs is fine and dandy but it doesn’t look like all the costs have been considered.  Have quality of care and better use of funding resources really been considered?  Do the benefits to research really out weigh the potential costs are use of everyone’s time, especially clinician time?  Decide for yourself and then provide input to Congress.