Dear Physicians,
After witnessing several years of vehement opposition to ICD-10 by organizations who serve the physician community, I am forced to come to the conclusion that those who claim to be looking out for you are not doing such a hot job when it comes to ICD-10. They are exaggerating the magnitude of the change and the cost it will be to your practice. Contrary to popular rhetoric, ICD-10 is not a conspiracy to put you out of business. It is simply an upgrade, and it need not be more disruptive than any other software upgrade. Here are a few reasons why.
For physician coders, only the diagnosis codes will change. CPT will continue to be used to report all outpatient procedures and professional services. ICD-10 diagnoses are by far less “exotic” than the ICD-10 procedures. ICD-10-CM diagnosis codes are a direct descendent of ICD-9-CM. The book itself is arranged exactly as it always has been, by body system or medical specialty chapter. In some chapters the difference in number of codes is fairly modest, and the new codes contain detail that you will most likely recognize and welcome. Here are a few examples, by specialty:
Gastrointestinal chapter: ICD-9 = 529 codes, ICD-10 = 691 codes. If you are a gastroenterologist, you will notice additional detail for coding hepatitis, Crohn’s disease and cholecystitis with associated cholelithiasis. And you will probably be glad to see the new codes, since the increased detail was added because your specialty society at the national or international level requested it.
Neoplasm chapter: ICD-9 = 958 codes, ICD-10 = 1,551 codes. If you are an oncologist, the number of ICD-10 codes in the neoplasm chapter is not even double. And if you actually run your eyeballs over the codes, you will see anatomic site detail (for example, you can now code whether the cancer is of the left or right ovary, which is a pretty handy thing to know) and more detailed codes for types of systemic cancers like leukemia.
Respiratory system chapter: ICD-9 = 230 codes, ICD-10 = 329 codes. If you are a pulmonologist, the number of diagnosis codes in the respiratory system chapter increases from 230 to 329. The increased detail includes the ability to further characterize the severity of asthma, respiratory insufficiency and respiratory failure. There are also new codes for influenza with detailed manifestations, and new detail for all the types of sinusitis, to indicate whether the sinusitis is recurrent or not. Again, the detail added to this chapter was at the request of the pulmonology community.
The increased number of codes is only interesting to pundits and salespeople. People who talk the number of codes must do it because they don’t have anything of substance to say about ICD-10. They trot out the numbers and let hang ominously in the air the false implication that because there are six times as many diagnosis codes, ICD-10 is six times harder to use. It is a simplistic notion that falls apart immediately if you actually crack the book and look at the codes. Overall, the increase in the number of codes, where it is dramatic, signals that a new level of detail was added consistently to a significant area of the classification. Adding the ability to capture the same level of detail everywhere does not equate to increased complexity. In fact, it does just the opposite. Codes that capture the same information everywhere are easier to correlate and compare meaningfully. Below are a couple of chapters where there are a lot more codes, and a brief explanation of where the increase is coming from.
Musculoskeletal system chapter: ICD-9 = 892 codes, ICD-10 = 6,327 codes. There are seven times as many ICD-10 codes as ICD-9 codes here, and the numbers can quite easily be accounted for by the fact that anatomic site detail was added consistently across the entire chapter. Sometimes that means three codes for every ICD-9 code, because left and right choices were added (an unspecified choice is available by convention, in addition to the left and right choices). Sometimes it means as many as 25 ICD-10 codes for every ICD-9 code, because the code is describing a condition of the joint and ICD-9 did not even specify which joint, let alone whether it was on the right or left side.
Injury and poisoning chapter: ICD-9 =2,572 codes, ICD-10 = 39,675 codes. Here is a whopping sixteen-fold increase in number of codes. For that reason, this chapter is a favorite target for journalistic cheap shots. But the principle behind the increase is the same as that seen in the musculoskeletal system example above, and anywhere else that the increase in number of codes is dramatic. For the CDC and state health departments to effectively track causes of injury, having all of the codes contain the same level of detail actually makes their job easier, not more difficult.
Keep in mind, every time you add a level of detail, the increase gets multiplied across all the codes that use that level of detail. Start with a single code like third degree burn of ear in ICD-9. In ICD-10 all burn codes specify whether a code is thermal or chemical, which doubles the number of codes. The ability to specify left and right triples that number of codes, and now we are up to six codes. In ICD-10, codes for subsequent treatment of this burn and for treatment of late effects of this burn have the same level of detail. So that brings us up to eighteen codes. You get the picture. If this level of detail, chemical or thermal burn, left or right ear, initial or subsequent treatment or late effect, is beyond the documentation and coding habits already established in your practice, I would be surprised.
Consultants and vendors who want your money are not the best estimators of how much ICD-10 will cost you. Consultants make their living solving problems for you. They may identify problems you didn’t know you had, and sometimes that can be good. But when they identify problems that don’t exist, that is not so good.
If you are told that the coders for your gastroenterology practice will be overwhelmed by ICD-10 unless they have an expensive all-day, off-site training seminar, you might want to confer with your coders and see what they actually need. A one-hour webinar may be all they need, with the understanding that they may have a few more queries than usual at first.
If someone claims it will cost you $5,000 to convert your super-bill to ICD-10, you can confidently counter, “$500 is about what it should cost.” With a decent translation tool, your super-bill can be ICD-10 ready in a couple of hours.
I hope this information is useful to you.
All the best,
Good article – very helpful to reassure physicians and avoid I-10 panic attacks
Thanks for some excellent information to counter the hype. The superbill information is particularly helpful.
I recall a fold-out six-page superbill in an ER where I had worked. Unfortunately for them, the changes in injury and poisoning codes may make such a superbill almost impossible unless eight-pages could accommodate?
For some practices, it will be the call to get computerized coding tools that will replace superbills containing code information. These coding search tools are not that expensive, either.
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Thanks for your comments. Some creative use of the consistency in the classification that I was talking about could be used to make a reasonable sized ER superbill possible. For example, every injury, poisoning and burn code has three different codes for describing whether the encounter is for initial treatment of the acute injury, subsequent aftercare, or treatment for a late effect. This information is always coded in the seventh character of the code and it uses the following letters: A=initial encounter, D= subsequent encounter, and S=sequela (late effect). Put these letters as a key at the top of the applicable page and you have reduced the number of codes by a factor of three. There is also much regularity in assigning the left or right body part, and this could be used as well to reduce the number of individual codes that have to be listed.
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Very true. What I still wonder about is to what level of specifity physicians will have to report new diagnosis codes to meet medical necessity requirements for the ancillaries that they order or to accurately protray their patient populations for cost-efficiency and risk-adjusted outcomes methodologies, such as Ingenix’s Episodic Treatment Groups or algorithms that 3M will be offering.
Wherever physicians are currently required to submit complete, valid ICD-9 diagnosis codes to meet federal regulatory requirements, they will also need to submit complete, valid ICD-10 diagnosis codes. According to guideline A3 of the official ICD-10-CM coding guidelines, “For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required.” Since physicians will need to have coded to the highest level of specificity to get paid, hopefully they will be motivated to reap the benefit of that specificity in the tools they use to understand their patient populations and how their costs and treatment outcomes compare with their peers. As I have already stated in my blog, I don’t believe physicians will find the level of specificity in ICD-10 diagnosis codes a documentation burden, and I believe in most cases physicians are already documenting sufficiently for ICD-10.
ICD-10-CM does not always require a 7th character either. If you read the guidelines thoroughly you will see that some codes may only be 3 characters and be valid. As always, the highest level of specificitiy is the key and always has been. I dread seeing a superbill in the ICD10 environment particularly since we have EHR and computer assisted coding methodologies, online methods are available to select the correct code, anything on a piece a paper that limits the clinicians alternatives for coding the primary code and any co-morbidities goes distinctly against the purpose of the ICD10 process.
All good points. Like you, I hope physicians will use the move to ICD-10 as an opportunity to improve their processes and outcomes and not just another regulatory hoop to jump through.
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