ICD-10 Benefits

Responding to Physician Criticism of ICD-10

Jason Gottlieb

Written by

See full article here.

For those physicians who have studied ICD-10 extensively, the overall impression among them is that it is a vast improvement over ICD-9. The most common criticism, the increased number of codes, should be addressed first.

It is true that the number of diagnosis codes in ICD-10 increases by approximately a factor of five over ICD-9. Many physicians bemoan the fact that they will have to learn five times as many terms as they knew under ICD-9. Yet this simply reflects a lack of knowledge. Consider, for example, a non-traumatic subarachnoid hemorrhage. Under ICD-9, this diagnosis fell under the categorical single code for subarachnoid hemorrhage. In ICD-10-CM, there is a specific category for non-traumatic subarachnoid hemorrhage featuring 20 specific codes. Going from one to 20 codes is a big leap. Does this reflect a lot of new learning for physicians?

Hopefully not.

What the code expansion actually represents is huge advances in clinical medicine made in the 35 years since ICD-9 was drafted. Specifically, we now have technology (CT/MRI/angiography) that can identify the specific artery involved (middle cerebral, basilar, anterior communicating, etc.) as well as laterality for many of those blood vessels. It is basic, responsible practice of medicine to identify the nature of the non-traumatic subarachnoid hemorrhage, in today’s clinical world.

Cardiology is a specialty for which terminology has improved significantly. The “new” terms for acute myocardial infarctions in ICD-10-CM are STEMI and NSTEMI (terminology that, incidentally, has been used by cardiologists, internists, and others for the last couple decades).

One area of legitimate concern among cardiologists relates to specificity regarding type of heart failure (acute or chronic, systolic, diastolic, or combined). Many cardiologists historically have not made such a differentiation, but they should acknowledge that this terminology is not new under ICD-10-CM – it’s also the codeable terminology found in ICD-9.

Is there a high degree of specificity in ICD-10-CM? Absolutely. And it is perhaps nowhere better exemplified than in orthopedic diagnoses. Just as an example, there are a myriad of codes for fractures of the femur. That sounds extreme until one actually learns how ICD-10-CM works. The new coding system includes terminology that every orthopedic resident must learn: the Gustilo classification of open fractures, the Salter-Harris classification of epiphyseal fractures, as well as other essential information such as specific anatomic site, type of fracture (spiral, etc.), and of course, laterality.

For neurosurgeons and trauma surgeons, ICD-10-CM includes provisions for the documentation of attributes of head injuries such as duration of loss of consciousness for cerebral edema as well as Glascow coma scores.

A comment from an internist in Anchorage, Alaska put ICD-10-CM into sharp perspective. He said (and I agree) that ICD-10-CM is exactly what we should expect from a resident in a morning report. So should we expect any less from practicing physicians? This observation should be reassuring to most physicians. I will admit, however, that the challenge is not the same for all specialties. Generalists, whether they are trained in family medicine, internal medicine, or emergency medicine, treat patients with a broad scope of diagnoses and will require more assistance transitioning to ICD-10-CM.

I should also mention ICD-10-PCS, the procedural coding system. Here we have a far greater increase in the number of codes. The marked expansion in the number of codes in ICD-10-PCS is primarily due to the architecture of the PCS system. ICD-10-PCS codes capture information impossible to capture in ICD-9, such as specific body parts, types of operations, types of devices left in a patient, and more. While this seems like it might present a lot more work for the physician, in most instances a quality operative report will include all the necessary information for coding, particularly if physicians are educated on basic code structure. It is unnecessary and absolutely not recommended that physicians memorize any ICD-10-PCS codes.

Let me share an observation from dealing with hospitals and medical staffs from across the country. The strongest physician advocates of ICD-10 appear to be those working in academic medical centers. That is, perhaps, because specificity and accuracy of diagnoses and procedure documentation are key components of residency and fellowship training. Additionally, most academic physicians recognize the lack of utility of ICD-9 for clinical research or epidemiology. ICD-10 provides much better information for such purposes.

I will conclude with one final observation. ICD-10 presents different challenges to different constituencies. I am very sympathetic to coders. They are essentially learning a new language, and they need to learn it for all specialties, all diagnoses, and all procedures. And here is where some of the confusion may have arisen for physicians who have not as yet learned much about ICD-10. We, fortunately, do not face the same challenges. For the vast majority of physicians, we can constrain our focus to our specialty areas.

In so doing, we quickly realize that the information needed for ICD-10 generally mirrors that which is required for high-quality patient care.

ICD-10 holds true promise for improved clinical terminology

Jason Gottlieb

Written by Dr. Abhishek Jacob

See full article here

It is common knowledge that ICD-10 CM & PCS code sets will increase granularity, improve axes of classification and provide a more scientific approach to coding, opening up tremendous growth in our understanding of disease conditions and associated treatment protocols.

For the first time in 36 years, we have the opportunity to revamp the clinical terminology being used to measure effectiveness of healthcare services, refine clinical grouping and associated reimbursement methodologies and enhance capability to conduct public health surveillance.

Today’s Challenges

  1. Many provider organizations believe that because ICD-10 has been characteristically complex to implement and includes many new and potentially amusing codes (e.g. W59.22XD – “struck by turtle, subsequent encounter”), the increased quantity may not be very useful from a treatment and re-imbursement perspective. These issues significantly undermine the potential benefits ICD-10 will have on documenting and reporting clinical conditions, enhancing clinical terminologies and, most importantly, measuring the effectiveness of treatments for better disease surveillance – like the current course of action and treatment during the recent outbreak of Ebola cited later.
  2. Though a competing priority, Meaningful Use (MU) implementation has a mutual dependency and benefit to ICD-10. One of the most important drivers of meaningful usage of EMR is allowing clinical data to be effectively utilized and shared between EHR systems. To accomplish this objective of using standard clinical terminologies, ICD-10 and MU requirements must be incorporated into EHR systems concurrently. This would help achieve comprehensive system interoperability and shed light on the benefits of a national health information infrastructure. ICD-10 and MU implementation are complimentary and are required to be applied together, and therefore should not be viewed as conflicting priorities.
  3. Last, rather than being used as a counterpoint to discredit the tremendous potential benefit of ICD-10 implementation, many of the so-called irrelevant codes, such as “struck by turtle, subsequent encounter,” fall in external causes of injury chapter and are not necessarily required for reimbursement of diseases surveillance, which means their usage can be restricted on a case to case basis.

ICD-10: The Next Generation of Clinical Terminology and Coding

ICD-10 holds true promise to expedite a much needed revamp of existing clinical terminologies and coding for high value patient encounters. Below is an analysis of a simple example that compares how ICD-10 provides significant enhancement to our ability to measure healthcare services and how increased sensitivity would assist in refining existing grouping and reimbursement methodology.

With more than 650,000 procedures per year, angioplasty in one of the most commonly performed operations, contributing approximately $13 billion per year to U.S. healthcare spending. According to a study published in The Journal of the American Medical Association in 2012, almost half of the angioplasties conducted in non-emergency situations may not benefit patients. In ICD-9 CM, angioplasty is represented by only 1 code- 39.50 and since ICD-9 CM lacks the granularity, it might not be possible to relate the clinical outcomes of the procedure with the associated reimbursement.

ICD-9-CM

Angioplasty – 1 code (39.50)

ICD-10-PCS

Angioplasty – 854 codes

ICD-10 CM not only specifies the body part the procedure was conducted on but also the approach, the device used and the type of stent placed. This granularity allows for correlation between clinical outcomes and a specific type of procedure, thereby improving the overall efficacy of the treatment.

Some examples of ICD-10 granularity of Angioplasty codes include:

  • 047K04Z – Dilation of right femoral artery with drug-eluting intraluminal device, open approach
  • 047K0DZ – Dilation of right femoral artery with intraluminal device, open approach
  • 047K0ZZ – Dilation of right femoral artery, open approach
  • 047K34Z – Dilation of right femoral artery with drug-eluting intraluminal device, percutaneous approach
  • 047K3DZ – Dilation of right femoral artery with intraluminal device, percutaneous approach

The granularity that comes with ICD-10 is critically important to the future of our healthcare system. The outbreak of Ebola has allowed many analysts and experts in the field to stress how ICD-10 and improved clinical terminology intensifies the need and benefits of the new code set. ICD-10 could allow healthcare providers to measure the effectiveness of treatments for better disease surveillance and outbreak response.

ICD-9 CM has no specific code for reporting Ebola hemorrhagic fever (EHF). The closest match is 065.8 “other specified arthropod-borne hemorrhagic fever.” ICD-10 CM has a specific code, A98.4 “Ebola virus disease.” In ICD-9 CM Ebola is classified under “arthropod-borne viral diseases” whereas in ICD-10 it is classified as “arthropod-borne viral fevers and viral hemorrhagic fevers.”

There is currently no drug or vaccine available to treat Ebola and most of the treatment is based on experimental drugs. Since the outbreaks, until now, have appeared prominently in Africa, where there is a very restricted use of standard clinical terminology and modern EHR systems, little information is available about the natural reservoir host of Ebola virus.

And as we’ve witnessed, because physicians aren’t able to accurately document the causative factors, strains of virus and treatment protocols, our response to the outbreak has been restricted to a tactical stoppage of spread. ICD-9 CM does not have any codes to document Ebola accurately, and though ICD-10 CM has only one code to report Ebola, the ability to expand the categorization in ICD-10 ensures that researchers, authorities and care providers can better prepare for response, resulting in potential lives and millions of dollars saved. This is a classic example of how accurate usage of clinical terminology for disease surveillance associated with ICD-10 implementation holds true promise.

Continued use of ICD-9-CM as a medical code set standard threatens to jeopardize the ability of the U.S. healthcare industry to effectively collect and use accurate, detailed healthcare data and information for the betterment of domestic and global healthcare. Clinical terminology modernization and standardization are amongst the most important steps required to maximize the power of healthcare data and, in doing so, build a better healthcare system for the 21st century.