ICD-10 Is No Laughing Matter, Duck Bites Aside

November 1, 2011 — Physicians have gotten a few laughs from the new and voluminous set of diagnostic codes known as ICD-10, which distinguishes between being struck by a duck (W6162XA) and being bitten by a duck (W6161XA).

A new study by the healthcare research firm KLAS, however, suggests that physicians and other providers need to take ICD-10, more seriously. Only 9% of providers are more than halfway through the needed preparations to switch from the ICD-9 code set to the new one by the federal deadline of October 1, 2013. The rest, said study author Graham Triggs, are still in the early stage of doing their homework.

The consequences of not submitting claims to Medicare and other third-party payers with the new diagnostic codes when the deadline arrives are dire, said Triggs, a senior research manager at KLAS.

"If claims aren't compliant with ICD-10, they won't get paid," Triggs told Medscape Medical News. "It could put providers out of business."

More than 95% of providers surveyed by KLAS were hospitals and health systems, said Triggs. "My guess is that physicians in independent practices are even less prepared."

Older Codes Said to Be Outdated, Lacking in Specificity

ICD-10 stands for the International Statistical Classification of Diseases, 10th Revision, which was developed by the World Health Organization. Like ICD-9, ICD-10 breaks down into 2 subsets: CM codes for diagnoses and PCS codes for procedures.

Physicians currently use Current Procedure Terminology (CPT) codes and those in the Healthcare Common Procedure Coding System (HCPCS) to document their services in office and outpatient settings. They will not switch from these codes to ICD-10 procedure codes, which are confined to inpatient treatment.

However, all physicians will need to make the leap from the ICD-9 diagnostic codes they use now to those of ICD-10. The new diagnostic codes are 3-7 characters in length, whereas their ICD-9 counterparts contain 5 at most. Then there is the difference in the sheer volume of codes — 68,000 for ICD-10 compared with 14,000 for ICD-9.

The Centers for Medicare and Medicaid Services (CMS) decreed the switch to ICD-10 in 2009 as part of implementing the Health Insurance Portability and Accountability Act (HIPAA). The rationale is that ICD-9, now 30 years old, contains outdated and obsolete terms, captures limited data about a patient's condition, and fails to describe current medical practice. Plus, its structure limits the number of new codes that can be coined.

With ICD-10, physicians will be able to document what ails a patient with far more specificity. ICD-9, for example, has a code for a malignant neoplasm of an arm, but ICD-10 offers 3 options: upper right arm, upper left arm, or unspecified arm.

Finally, a Code for Walking Into a Lamppost

Such multiple choices help explain why the new code set is almost 5 times larger than the old one. However, some may wonder whether the authors of ICD-10 got carried away in covering every base.

ICD-9, for example, recognizes that patients may seek treatment because they were bitten, and gives clinicians a few choices, such as dog, rat, snake, arthropod, unspecified animal, or human. ICD-10, in contrast, is a veritable zoo of bite codes — horse, cow, cat, pig, shark, dolphin, sea lion, alligator, macaw, parrot, and duck, to name just a few new kinds of jaws. And for each kind of bite, physicians can pick a code for an initial encounter, subsequent encounter, or sequela.

ICD-10 also describes the world of bumps and bruises in excruciating detail, with codes for walking into a wall versus a lamppost versus a piece of furniture. Ever been crushed between a sailboat and another kind of water craft? There's a code for that, too — V9114XA.

Some accident codes, however, defy the imagination, such as the famous V9107XA: burn due to water-skis on fire, initial encounter.

Develop a Master Plan and a Budget

Physicians may never need to look up the diagnostic code for a macaw bite, but they nevertheless must prepare to leave behind ICD-9 for ICD-10. There still is enough time to do so, according to Graham Triggs at KLAS.

Vendors of practice management and electronic health record (EHR) systems will perform much of the heavy lifting in the changeover because they need to incorporate the new codes in their software. Physicians should check in with their vendors and make sure they are on track with updating their programs to comply with ICD-10 along with the new Version 5010 HIPAA standards for electronic healthcare transactions, which take effect next year. Medical practices, of course, will need to buy the latest version of their practice management and EHR software and test it before going live with ICD-10 on October 1, 2013.

Even with software vendors doing their part on the tech end, physicians still have to invest sufficient time and money in training themselves and their staff — especially professional coders — on how to use the new diagnostic codes. Sources of that schooling range from software vendors to practice-management consultants to a network of ICD-10 trainers approved by the American Health Information Management Association (AHIMA).

All this preparation requires a master plan and somebody in charge of executing it. It also requires a budget. Besides spending money on software upgrades and training, practices should set aside some cash in the event that coding snags delay the payment of insurance claims. The Medical Group Management Association (MGMA) estimated in 2008 that a 3-physician practice would shell out a grand total of $84,000 to implement the new code set.

Physicians seeking further guidance on entering the ICD-10 era can find plenty of it on the Web sites of the MGMA, AHIMA, American Medical Association, their specialty medical society, or CMS.