Preparing for ICD-10
Five Steps for a Successful Transition
March, 20 09
On January 16, 2009, the U.S. Department of Health andHuman Services (HHS) published an October 1, 2013 implementation date of the 10th revision of the International Classification of Disease (ICD-10).
While the change of date to October 2013 from the October 2011 date published in the notice of proposed rulemaking (NPRM) may afford the healthcare community more time to prepare for the transition, it still represents an aggressive time frame. Health plans need to act now to address the broad impact of the ICD-10 transition across their health system enterprise.
A World of Change
Much of the rest of the world – and all of the other Group of Eight (G8) countries – have already implemented the 10th revision of the International Classification of Diseases (ICD-10) code set. In contrast, the U.S. continues to use the previous code set known as ICD-9. The complexity and magnitude of the changes, combined with the sheer size and diversity of the healthcare market in the U.S., has until now forestalled implementation of ICD-10 in this country.
The U.S., however, has begun to take critical steps to prepare for the transition to ICD-10 – beginning with HHS’ Final Rule that replaced the ICD-9-Clinical Modifications (CM) code set with a greatly expanded ICD-10 code set, and required compliance as of October 1, 2013.
Transition from the 30-year-old ICD-9 code sets to the newer code set will cause fundamental changes that will reverberate throughout all healthcare and related organizations, including providers, payers, clearinghouses, third-party administrators, self-insured employers, laboratories, software vendors, consumers, national organizations, government health programs and suppliers.
Nevertheless, the inevitable process of ICD-10 adoption has begun, and healthcare organizations need to start planning now to ensure a successful transition. The benefits, once the
International Classification of Diseases in Brief
ICD is published by the World Health Organization (W.H.O.), which is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. Its published ICD is used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. The design of the coding system promotes international comparability in the collection, processing, classification and presentation of these statistics. The ICD, as published by W.H.O., contains only diagnosis codes. W.H.O. revises the ICD code set periodically, and it is currently in its 10th edition.
ICD-10 represents a fundamental overhaul of the previous ICD-9 coding system. The volume of ICD-10 codes as compared to ICD-9 codes is significant because of the following:
1.Expanded field size
2.Completely redefined code values and their interpretation 3.A more extensive level of specificity
In addition, the X12 standard 5010 is mandated for adoption
ICD-9
ICD-9-CM diagnosis codes • 3 - 5 digits
• Approximately 14,000 codes ICD-9-CM procedure codes • 3 to 4 digits
• Approximately 4,000 procedures
ICD-10
ICD-10-CM diagnosis codes • 5 - 7 digits
• Approximately 68,000 diagnosis codes ICD-10-PCS procedure codes • 7 digits
• Approximately 72,000 procedures
Figure A: There is a Significant Increase in Code Volume when Comparing ICD-10 to ICD-9.
Global ICD-10 Adoption
W.H.O. endorsed ICD-10 in May 1990, and many of the more than 190 Member States have used it since 1994. One-hundred, thirty-eight countries have implemented the ICD-10 code set for mortality, and 99 of them have implemented ICD-10 for morbidity. (The U.S. adopted ICD-10 for mortality data only in 1999.)
Although W.H.O. endorses a base version of the code set, individual countries may apply for, and be granted permission to develop, a national clinical modification to augment the basic code set with additional codes to meet their national needs. For example, Canada and Australia each have a national version of the ICD-10 code set. Likewise, W.H.O. granted permission to the United States to develop a national clinical modification of ICD-10. The effort involved the U.S. National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). NCHS created ICD-10-CM, which contains diagnosis codes. The ICD-10-Procedure Coding System (PCS) was delveloped for CMS, which contains the procedure codes for use in reimbursement of in-patient hospital services. The ICD-10 CM code set is five times larger than the code sets being used in other countries (68,100 ICD-10 CM codes compared to 12,420 ICD-10 codes endorsed by W.H.O.).
Why ICD-10 and Why Now?
The Final Rule, published in the Federal Register in January 2009, mandates an October 1, 2013 compliance date for ICD-10. HHS will require that all services provided on, or after October 1, 2013, be submitted with ICD-10 CM diagnosis codes and that all inpatient hospital claims be coded with ICD-10 PCS codes.
An excerpt from the Final Rule states: “…as a global community, it is vital that our healthcare data represent current medical conditions and technologies using codes compatible with the international version…”
Although four years seems like a long time, it still represents an extremely aggressive timeframe. Health plans need to act now to address technical challenges of achieving compliance, and to make changes to business processes that will optimize the benefits of ICD-10.
The costs and the potential for disruption caused by implementing ICD-10 are considerable, but the benefits are potentially greater.
ICD-10-CM and ICD-10-PCS incorporate greater specificity and clinical detail to provide information for clinical decision making and outcomes research. Together the ICD-10-CM and ICD-10-PCS codes have the potential to reveal more about quality of care, so that data can be used in a more meaningful way to better understand complications, better design clinically robust algorithms, and better track the outcomes of care. The 30-year-old ICD-9 coding system is outmoded, based on the medical knowledge of a different era. According to CMS, ICD-9 “has outdated and obsolete terminology, uses outdated codes that produce inaccurate and limited data, and is inconsistent with current medical practice. It cannot accurately describe the diagnoses and inpatient procedures of care delivered in the 21st century.”
Its age and the inevitable march of medical progress have brought us to the present juncture. ICD-9 no longer meets the healthcare industry’s needs:
• It is running out of space for additional codes, especially in certain categories;
• It is not logically organized – certainly not after numerous Publish Proposed Rule
Begin Initial Compliance Activities(assessment, planning, training, design, remediation, testing)
Final Rule Published ICD-10 Compliance
Jan 2009 Oct 1, 2013
Aug 2008
“Our best guess is that the cost of conversion will run $425 million to $1,150 million in one-time costs plus somewhere between $5 million and $40 million a year in lost productivity ... For benefits, the total is $700 million on the low end to $7,700 million on the high end.”
additions that are not located where those additions would logically be expected;
• It does not provide an optimal level of detail for research, payment and treatment uses;
• It has been left behind by the majority of other countries in favor of ICD-10 or a national version of ICD-10.
Electronic health records (EHR), personal health records (PHR) and other online healthcare systems would benefit from the higher level of detail and accuracy provided by the use of ICD-10 code sets. This would allow the healthcare community to automatically process more information related to diagnosis and procedure codes.
ICD-10 Mappings
General Equivalence Mappings (GEMs) were developed for CMS to provide assistance in translating from one version of ICD to another.
The GEMs, however, can offer only limited guidance. According to CMS: “Mappings between ICD-9 and ICD-10 attempt to find corresponding procedure codes between the two code sets, insofar as this is possible. Because the two systems are so different, translating between them the majority of the time can offer only a series of possible compromises rather than the mirror image of one code in the other code set.”
ICD-10 Diagnosis Codes
One of the fundamental challenges posed by the transition to ICD-10 is that there are many diagnoses in both code sets that do not have an exact one-to-one match in the other code set. Mappings from ICD-9-CM to ICD-10-CM may be: one-to-one, one-to-many, or many-to-one (see Figure B). Additionally, there are diagnostic codes in ICD-10-CM that have no equivalents in ICD-9-CM, and in ICD-9-CM that have no matches in ICD-10-CM.
ICD-10 Procedure Codes
Mapping between ICD-9-CM and ICD-10-PCS procedure codes is even more complex than the mapping of diagnosis codes between the two ICD versions. ICD-9-CM poses an additional challenge because it contains component codes that do not identify a procedure, but instead specify in greater detail an aspect of a procedure, such as the number of stents used in an angioplasty. These ICD-9-CM component codes must be
paired with an ICD-9-CM “primary procedure” code to be meaningful. In comparison, every ICD-10-PCS code is a complete procedure code – there are no ICD-10-PCS component codes.
ICD-9-CM Code(s) 1-to-1 Relationship (Exact) 003.21 Salmonella meningitis 1-to-1 Relationship (Approximate) 003.29 Other localized salmonella infections
1-to-Many
250.X Diabetes mellitus 4th digit identifies type of complication,
5th digit ‘1’ – is identified juvenile-onset,
‘0’ adult-onset
ICD-10-CM Code(s)
A02.21 Salmonella meningitis
A02.29 Salmonella with other localized infection
E08 Diabetes due to underlying condition
E09 Drug or chemical induced diabetes
E10Type 1 diabetes E11Type 2 diabetes E13 Other specified diabetes mellitus
E14 Unspecified
4th digit identifies type of complication,
5/6th digit for type of complication Many-to-1
010.00 Primary tuberculosis infection unspecified examination 010.001 Primary tuberculosis infection bacteriological / histological examination not done 010.002 Primary tuberculosis infection bacteriological / histological examination unknown (at present) 010.003 Primary tuberculosis infection found by microscopy 010.004 Primary tuberculosis infection found by bacterial culture
010.005 Primary tuberculosis infection confirmed histologically 010.006 Primary tuberculosis infection confirmed by other methods
A15.7 Primary respiratory tuberculosis
ID-10-CM Codes with No Equivalents in ICD-9-CM
N/A Z72.3 Lack of Physical Exercise
Z72.4 Inappropriate diet and eating habits
Z73.1Type A behavior pattern Z73.2 Lack of relaxation and leisure
The examples in Figure C demonstrate some of the complex-ities and problems involved in cross walking ICD-9-CM procedure codes to ICD-10-PCS procedure codes:
The complexity of mapping ICD-9 to ICD-10 and vice versa is depicted in Figure D and Figure E, which clearly show the ratio of one-to-one matches.
Challenges to a Successful ICD-10 Transition
Implementation of ICD-10 in the U.S. has been likened to the Year 2000 (Y2K) update of information systems in terms of breadth of impact and cost.
In reality, the transition from ICD-9 to ICD-10 will be more complex and potentially more costly. It will impact virtually every department of every healthcare organization. Like Y2K, the transition to ICD-10 carries direct financial risk because it is related to, among other things, billing and revenue management. According to Gartner, however, the transition to ICD-10 “ripples throughout the entire care delivery management cycle.”
Furthermore, Y2K involved altering only the format of date, not the actual date information. In contrast, the transition from ICD-9 to ICD-10 involves using a coding system that contains fewer than 14,000 diagnosis codes to more than 68,000 diagnosis codes and approximately 4,000 procedure codes to 72,000 procedure codes.
The more extensive and detailed ICD-10 codings pose considerable challenges to personnel training, organization processes and information architecture.
ICD-9-CM Code(s)
1 (Multiple Operation) to Multiple (Single Operation) 65.63 Laparoscopic removal of
both ovaries and tubes at same operative episode
ICD-10-PCS Code(s) :
0UT24ZZ Resection of bilateral ovaries, percutaneous endoscopic approach 0UT74ZZ Resection of bilateral fallopian tubes, percutaneous endoscopic approach Figure C: Sample ICD-9 to ICD-10 Procedure Mapping
1 to Many (More Detailed) 02.11 Simple suture of Dura Mater of brain
00Q20ZZ Repair of Dura Mater, open approach
00Q23ZZ Repair of Dura Mater, purcutaneous approach 00Q24ZZ Repair of Dura Mater, purcutaneous endoscopic approach
ICD-9-CM Component Codes with No Equivalents in ICD-10-PCS 00.40 Procedure on single vessel
00.41 Procedure on two vessels 00.76 Hip replacement bearing surface, ceramic-on-ceramic 00.77 Hip replacement bearing surface, ceramic-on- polyethylene 00.91Transplant from live related donor
00.92Transplant from live non-related donor
00.93Transplant from cadaver
N/A
Figure D: Analysis of the GEMS Diagnosis File Mapping Flags
ICD-9-CM to ICD-10 Not Mapped Mapped One to One
Approx. Mapping GEM File Record Count
ICD-10-CM to ICD-9 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0
Figure E: Analysis of the GEMS Procedure File Mapping Flags
ICD-9-CM to ICD-10 Not Mapped Mapped One to One
Approx. Mapping GEM File Record Count
ICD-10-CM to ICD-9 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0
To complicate matters more, mapping code translations from the ICD-9 system to ICD-10 system are not straightforward. Mappings from ICD-9 codes to ICD-10 codes can take a number of different paths (e.g., one-to-one, one-to-many, many-to-one). Furthermore, there are numerous ICD-10 diagnosis codes that have no equivalent in ICD-9, and numerous ICD-9 component procedure codes that have no equivalent in ICD-10.
For better or worse, a single cut-over – covering all impacted information systems is not possible, according to Gartner. As a result, healthcare organizations (HCOs) need to develop a plan that identifies the most appropriate transition sequence, and they must consult closely with their numerous business partners (payers, software vendors, etc.) to make sure that all parties are following a sequence that ensures continuous systems interoperability and efficient deployment of resources. While CMS has issued a single implementation date for ICD-10, business systems must be evaluated and business partners coordinated on an individual basis.
Areas of Impact: Everywhere
The transition to ICD-10 will impact critical systems at hospitals, physician practices, payers and clearinghouses. Coded health data are used in core functions throughout the healthcare industry, including reimbursement, research, reporting, strategic planning, healthcare funding, quality measurement and pay for performance.
The following list, compiled by the American Health Information Management Association (AHIMA), provides a snapshot of the breadth of impact that healthcare organizations can expect. The transition to ICD-10 will impact all of these functions:
• Measuring the quality, safety (or medical errors) and efficacy of care
• Making clinical decisions based on output from multiple systems
• Designing payment systems and processing claims for reimbursement
• Conducting research, epidemiological studies and clinical trials
• Setting health policy
• Designing healthcare delivery systems • Monitoring resource utilization
• Improving clinical, financial and administrative performance • Identifying fraudulent or abusive practices
• Managing care and disease processes • Tracking public health and risks
• Providing data to consumers regarding costs and outcomes of treatment options
Implementation of ICD-10 will impact the entire value chain of healthcare insurance and delivery, including scheduling, patient registration, patient care, customer service, revenue and reimbursement management, network management and risk management.
Five Steps for Beginning a Successful ICD-10 Transition
A successful ICD-10 implementation plan must encompass the entire organization. It should identify specific actions and assign responsibilities and deadlines for achieving them, including changes to processes, policies and procedures, as well as educational needs. It should also identify any need for increased staffing or consulting services to assist with coding backlogs, “The scale of the change is enormous. Diagnosis and procedure codes are used in billions of transactions per year by hundreds of thousands of providers and hundreds of payers. The odds of flawless implementation by this complex web of players are virtually zero.”
- Robert E. Nolan Company, “Replacing ICD-9-CM with ICD-10-CM and ICD-10-PCS: Challenges, Estimated Costs, and Potential Benefits”, October, 2003.
monitoring of coding accuracy, etc., as well as system upgrades or changes necessary to accommodate the new code set. The health plan should establish a budget for accomplishing the transition and estimate the financial impact the expected loss of productivity and disruptions in cash flow will have.
1. Establish an enterprise-wide implementation committee. The ICD-10 implementation committee must be composed of representatives from all key stakeholders, including, but not be limited to, representatives from health information management (HIM), senior management, medical staff, financial
management and information systems. A project manager must be appointed to serve as leader of this committee, be a champion for change, coordinate meetings and be responsible for the entire project. The committee members should have a working knowledge of ICD-10 and how it differs from ICD-9, as well as the expected short- and long-term financial and personnel impact of the implementation. The committee must develop an implementation plan with timeframes.
2. Conduct an ICD-10 impact assessment.
The impact assessment must identify the impact on key business processes, including health plan contracts and coverage determinations. It should also identify any contract modifications that may be necessary to accommodate the greater specificity required for ICD-10 and any resulting adjustments to payment terms. Additional documentation requirements and new diagnostic codes may also cause revisions in coverage determinations.
Current data flows, work flows, operational processes, policies, procedures and reports that will be affected must be documented and evaluated. Consideration must be given to the necessity of accommodating two versions of the ICD code sets for an extended period of time. How long both code sets will be supported, what additional storage capacity will be necessary, when, and if, it makes sense to convert historical data, and how long forward and backward mapping will be available are all points to consider.
3. Create a documentation improvement plan. Because of the higher level of specificity required under ICD-10, it is important to ensure the adequacy of clinical documentation to support code assignment under the new system. This can be accomplished by evaluating random samples of medical records to identify areas where
documentation is lacking, as well as diagnoses and procedures that will require a higher level of detail. Once documentation deficiencies are identified, you should address any weaknesses and development requirements for monitoring and improving documentation practices. You should implement the plan prior to the transition to ICD-10 and should include ongoing monitoring of the improvement progress. The documentation improvement strategies identified in the assessment can also serve as the foundation of staff educational programs. 4. Assess staff educational needs.
You should conduct a detailed assessment of staff educational needs, budgetary estimates and the timing of educational programs. Because ICD-10 is more granular and detailed, even professional coders and billing specialists who are very comfortable with ICD-9 will require specific training to become proficient with the new diagnostic codes and documentation requirements.
Education cannot focus solely on coding and billing staffs. You will also need to educate the IT staff on the difference between ICD-9 and ICD-10 to determine whether current systems and interfaces should be built or modified in any way. You will need to establish multiple categories of users for identifying the varying levels of education that will be required on the new coding system. Additionally, the organization will need to determine the best method of providing education and the timing of the education for each category of users. 5. Coordinate with business partners.
It is important for providers to sit down with payers early in the process to gain a clear understanding of what they expect under ICD-10, establish when they will be ready to begin receiving claims coded under the new system and determine what, if any, “The impact of changing from ICD-9 ripples through pre-admission processes, care delivery, medical record abstracting, post hoc analysis of billing data for financial and clinical improvements, and fee-schedule negotiations with payers.”
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interim plans they have. Organizations that utilize a billing service or clearinghouse, should meet with those vendors to ascertain their plans for rolling out ICD-10 and for supporting the organization during the transition period.
Software vendors may, or may not, be able to provide clients with upgrades that allow them to automatically produce coder-ready documentation appropriate for ICD-10, or to accommodate the dual-coding environment that will likely be necessary during the early days of deployment. It is important to meet with vendors early in the process to ascertain exactly what role they will play in the transition process, any support they can, or will provide, and any costs for them to do so. Key issues to discuss include vendor readiness and timelines for upgrading software to new coding systems and whether or not upgrades are covered by existing contracts. It will also be necessary to coordinate any software or upgrade installations and testing. Healthcare organizations need to act now to minimize risk and cost, and maximize the opportunities for realizing the efficiencies that ICD-10 ultimately can provide.
Author and ICD-10 Industry Expert
Deborah Westervelt is the Managing Director in General Dynamics Information Technology’s ViPS ICD-10 Practices Group. ViPS is the applied healthcare information technology arm of General Dynamics IT’s Healthcare Sector. For more information, visit www.vips.com, email us at info@vips.com or call1-888-545-8477,ext. 8010.
References
Martin Libicki and Irene Brahmakulam, “The Costs and Benefits of Moving to the ICD-10 Code Sets,” RAND Corporation, March, 2004.
Wes Rishel, “Architecture for the ICD-10 Mandate in Care Delivery Organizations,” Gartner, February, 2008.
“Replacing ICD-9-CM with ICD-10-10-CM and ICD-10-PCS; Challenges, Estimated Costs and Potential Benefits,” Robert E. Nolan Company, October, 2003.
U.S. Department of Health and Human Services (HHS) news release: “HHS Proposes Adoption of ICD-10 code Sets and Updated Electronic Transactions Standards,” August 15, 2008. U.S. Department of Health and Human Services (HHS) news release: “HHS Establishes October 1, 2013 for ICD-10 Implementation Date,” January 15, 2009.
