Coding in Germany - The Use of ICD-10 for Diagnoses

Th. Mansky, HIMSS 2012 1

Coding in Germany - The Use of

ICD-10 for Diagnoses

Dr. Thomas Mansky, TU Berlin

Conflict of Interest Disclosure

Dr. Thomas Mansky

 Other: Travel expenses related to conference partially paid

3

Learning Objectives

 How ICD-10-CM increases the level of details

 For two examples understand what kind of details were added in

ICD-10 diagnosis coding

 Do all details matter clinically?

 There is no new medicine

 But new information is needed for coding

 Translation is not enough, revision of coding strategies is needed

 What technical changes are there affecting IT demands?

Coding in Germany

 ICD 9 used for inpatients since 1986

 ICD 10 introduced for inpatients 2000

 ICPM-based procedure coding since 1995

 G-DRG introduction 2003

5

Coding in Germany

 In Germany coding is mostly done by the doctors treating

the patients

They know what they treated

 In the USA coding is mostly done by professional coders

Level of Detail

Classification # of Codes Germany # of Codes USA ICD-9-CM # of Codes USA ICD-10-CM ICD-10 13,348 13,000 68,000 Procedures 27,990 4,000 72,000 DRG (2011) 1,194 747

7

Medical View

 The basic structure of ICD-10 is very similar to ICD-9

 In many cases ICD-10 is medically more appropriate than

ICD-9

 ICD-10-CM is much more detailed

 For doctors who are directly involved in the treatment it

Example: Stroke ICD-9-CM / 1

 433 Occlusion and stenosis of precerebral arteries

• 0 without mention of cerebral infarction • 1 with cerebral infarction

 433.0 Basilar artery  433.1 Carotid artery  433.2 Vertebral artery

 433.3 Multiple and bilateral

 433.8 Other specified precerebral artery  433.9 Unspecified precerebral artery

 6 possible codes for this type of cerebral infarction (with occl./stenosis of precerebral arteries)

Example: Stroke ICD-9-CM / 2

 434 Occlusion of cerebral arteries

• 0 without mention of cerebral infarction • 1 with cerebral infarction

– .0 / .1 / .9 <affected artery>

 435 Transient cerebral ischemia

 .0 / .1 / .2 / .3 / .8 / .9 <affected artery>

 436 Acute, but ill-defined, cerebrovascular disease

– Apoplexy, apoplectic: – NOS – Attack – Cerebral – Seizure – Cerebral seizure

Example: Stroke ICD-10-CM

I63 Cerebral infarction

 I63.0 Cerebral infarction due to thrombosis of precerebral arteries  I63.01 Cerebral infarction due to thrombosis of vertebral artery

– ...

 I63.03 Cerebral infarction due to thrombosis of carotid artery

 I63.031 Cerebral infarction due to thrombosis of right carotid artery  I63.1 Cerebral infarction due to embolism of precerebral arteries

– ....

 I63.2 Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries – ...

....

 I63.4 Cerebral infarction due to embolism of cerebral arteries  > 70 codes

11

Example: Stroke

 The unspecific code I64 (corresponding to '436 ill-defined

disease' in ICD-9) which is present in WHO ICD-10 has (intentionally) been omitted in ICD-10-CM

 This supports more precise coding for reimbursement

What is different ?

 ICD-9-CM:

 Occlusion (unspec.) – affected artery (6) – with/without infarction

 ICD-10-CM

 Infarction

 type of occlusion: thrombosis / embolism / unspec. // special)

 affected artery: unspec. precerebral / vertebral / carotid / basilar / unspec. cerebral / middle – anterior – posterior cerebral /

cerebellar / venous thrombosis / other / unspec. (>11)  side: right / left (where applicable)

13

ICD-10-CM Advantage

 The hierarchy changed, i.e. the Cerebral Infarction (major

form of stroke) has become an entity of its own

 This is basically more appropriate with respect to the

ICD-10-CM Disadvantage

 The CM adds a lot of details:

– I63.031 Cerebral infarction due to thrombosis of right carotid artery

– I63.131 Cerebral infarction due to embolism of right carotid artery

 While this is a good nosologic view of the disease, in many

patients it would require sophisticated scientific investigations to find out which it was

15

Medical Practice (stroke)

 A doctor would usually state that there was an ischemic

stroke due to stenosis (or occlusion) of the right carotid artery, thus the code would be:

 I63.231 Cerebral infarction due to unspecified occlusion

What Do We Learn Here?

 There are many details in ICD-10-CM, but in real life many

may not be used as the clinical information is not present to such level of detail and sometimes not even relevant for

treatment

 Other medically important details, which are usually known

(e.g. degree of stenosis as known from Doppler-Ultrasound) are unfortunately missing

17

Stroke: Walk from 9 to 10

 Stroke codes of ICD-9-CM did not contain many of the

details required for ICD-10-CM

type of occlusion (embolism etc.) and affected artery (carotid etc.) did not have to be coded or were less detailed

 Consequence: A simple mapping list would not help at all

 Moving from more detail to less is easy, moving from less

Stroke: From 9 to 10

 Medically nothing will change: Much of the additional

information needed is already there in the medical record today, but it has to be found and coded in a new way in future

 Remember: There are new things to look for and to

19

Example: Hip Fracture in ICD-9-CM

 820 Fracture of neck of femur

– 820.0 Transcervical fracture, closed – 820.1 Transcervical fracture, open – 820.2 Pertrochanteric fracture, closed – 820.3 Pertrochanteric fracture, open

– 820.8 Unspecified part of neck of femur, closed

 Hip NOS

 Neck of femur NOS

Example: Hip Fracture in ICD-10-CM

 S72.0 Fracture of head and neck of femur

– with 36 subcodes

 S72.1 Pertrochanteric fracture

– with 27 subcodes

21

ICD-10-CM Hip Fracture Details

 Right / left

 Part: unspecified, intracapsular, epiphysis, midcervical,

head, neck ...

 Displaced / nondisplaced

 Many very specific details which might be found in X-ray- or

What Do We Learn Here?

 Again: Medically nothing would change; information is

already there, but has to be found in the record

 The details are again listed in a very systematic and

detailed way, but probably more detailed than needed for purposes like reimbursement

23

Further Remarks

 Time is not sufficient to go through all details

 It should be mentioned, in short, that external causes of

morbidity (E-codes in 9) have been integrated in ICD-10

 The chapter covering mental and behavioural disorders has

undergone a major revision as compared to ICD-9 (this is less DRG-relevant)

What Do We Learn?

 Coders need to find very specific information in the medical

record, which was not needed before

 Usually this information would often already be somewhere

in the medical record

 In some cases physicians might have to add details which

25

Focus on What is Important

 Not all details in ICD-10-CM will be important for

reimbursement

 For each major disease, find out what would probably be

the details needed for DRG differentiation

– e.g. DX causing different ressource use – many DX codes may leed to same DRG

Don't Forget CCs !

 Analyze coding of comorbidities and complications in your

hospital

 Check the more important codes against the new ICD-10

CC-list contained in the new DRG manual as soon as it becomes available

 Make sure that more specific codes are used, if

27

Do Not Change Medicine

 Medical diagnosis and treatment must serve the patient,

not the coder

 The issue must be to clarify what information is there as

part of the medical process and where it can be found in the record

 Do not require information just because there are codes

Source of Information

 Coders will often have to use some information from the

medical record, which they did not need previously

– X-ray, OR-report, ultrasound etc.

 This requires a lot of learning and new understanding

29

Affected Areas in Coding

 Codelists or hitlists may be present at many different sites

in your hospital

– X-ray, OR, endoscopy, laboratory for infection codes, etc. etc. etc.

Other Affected Areas

 ICD codes might be used in very different (non-medical)

areas – for example, contracting

 All these areas have to be identified

 The codes used must be revised according to their purpose;

simple translation will often not be sufficient

 Teamwork between coders, physicians, administration is

advisable

 Other areas should be updated externally – for example,

quality control

31

Some IT Problems

 ICD-10-CM is alphanumeric (ICD-9 was in some parts) with

up to 7 characters

 If there (still) would be systems, which treat the ICD code

as a numeric field or if the fields are too short, action would be needed

 Code reference tables have to be updated where

necessary (similar to yearly ICD-9-CM updates)

 Statistics might have to be revised if certain aggregation

levels are needed

 Checklist: Where is ICD used in my system? What must be

High Importance

 Need to update any process that uses ICD-9 codes today

before ICD-10 goes live

 Management process, top level involvement needed

 Coders may take the lead in practice

33

Relation to DRG Reimbursement

 In the beginning many new details will not have major

effects on DRGs as cost differences are not yet known

 Many codes differentiating new details will end up in the

same DRG, thus the risk of transition is limited (but not zero)

 After a few years new details might be used for more

Risks for Reimbursement

 If appropriate care is taken in coding, the risks for

reimbursement should be limited

 However this cannot be taken for granted – good

35

Conclusions

 ICD-10-CM diagnosis coding will require new clinical

information

 Simple mapping of ICD-9 to ID-10 is not enough; revision of

information requirements and work flow is needed

 Use of ICD code lists in the hospital has to be identified and

appropriately adopted

 A well managed revision process has to be set up

 There are risks to reimbursement, which should be limited if

Thank you !

Prof. Dr. Thomas Mansky

Technische Universität Berlin Strasse des 17. Juni 135

D 10623 Berlin GERMANY