Pediatricians must learn the nuances of new ICD-10 coding and prepare for the transition now! Dr Schuman presents the reasons behind ICD-10 implementation as well as key elements of ICD-10 adoption to assure a smooth transition for your practice.
The United States adopted its version of the World Health Organization’s (WHO) International Classification of Diseases version 9 (ICD-9) coding system over 30 years ago. These are the billing codes we use for every patient encounter (eg, 382.9, V20.2), and pediatricians know many of these by heart. By October 1 of this year, we are required to begin using the International Classification of Diseases, version 10 (ICD-10). The start date for ICD-10 already has been delayed twice over the past 2 years, but at this point the transition date of October 1, 2015, appears to be firm. Therefore, pediatricians must learn the nuances of the new coding system and prepare for the transition now! In this month’s article, I present the reasons behind ICD-10 implementation as well as key elements of ICD-10 adoption to assure a smooth transition for your practice.
The WHO developed ICD-10 in 1990 as a more technically capable coding system to replace ICD-9, and most industrial nations already have adopted this coding set. The ICD-10 has more than 69,000 codes- 55,000 more diagnosis codes than ICD-9. In 1993, the National Center for Health Statistics (NCHS) modified WHO’s version of the ICD-10 code set to more appropriately meet the needs of the American system.
The updated code set is called the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). For the remainder of this article, I will refer to ICD-10-CM as ICD-10. Note that NCHS also developed a procedure code set for hospitals to bill for inpatient services, called ICD-10 PCS, which is unique to the United States.
There are many reasons why ICD-10 was developed. We now practice in an era of “big data,” in which patient care is monitored by government agencies such as the Centers for Medicare and Medicaid Services and Health and Human Services, as well as insurance companies. This data is used to monitor compliance with national programs such as meaningful use, the medical home initiative, and others, and can facilitate the comparison of physician “quality.”
According to the Centers for Disease Control and Prevention website, the ICD-10 code set will enhance the quality of data for:
· Tracking public health conditions (complications, anatomical location);
· Improved data for epidemiological research (severity of illness, comorbidities);
· Measuring outcomes and care provided to patients;
· Making clinical decisions;
· Identifying fraud and abuse;
· Designing payment systems/processing claims systems.
Additionally, US adoption of ICD-10 will facilitate the comparison of our morbidity and mortality data to those published internationally. The ICD-9 has been limited regarding many of the details needed to qualify a patient encounter. It cannot detail right versus left otitis media; detail the cause of a medical condition or factors contributing to it; or determine whether a visit is for an initial evaluation of a medical problem or a subsequent encounter.
The transition to ICD-10 may seem far off at this point in time, but if you procrastinate your conversion may not go smoothly. There are several things to consider. First, you will need to work with your electronic health record (EHR) software vendor to determine what steps are necessary for ICD-10 conversion. Will there be a charge for an upgrade or will updated software be provided free of charge? Because the ICD-10 code set differs in many respects from our familiar ICD-9 codes, you and your staff will need training to prepare for the conversion. Your coders, if you code and/or bill in-house, will need training to use ICD-10.
Perhaps most important is that you start to dialogue with the payers regarding whether they are prepped for the conversion and what you may be required to do in terms of billing and documentation. Electronic billing requires software upgrade to be ICD-10 compliant. Does your office use superbills of lab forms? If so, you will need to revise the diagnostic codes they display. Unfortunately, it is estimated that the ICD-10 will be costly when you figure in training, software conversions, and so on anywhere from $56,639 to $226,105 per practice for a small medical practice and many times this number for larger practices.1
Practices also may need to increase cash reserves or establish a line of credit in case payments from insurance companies get disrupted or claims rejected because of documentation problems. It is estimated by some that the switch from ICD-9 to ICD-10 will negatively impact office productivity by at least 6%.2
According to the American Association of Professional Coders, when the ICD-10 system was implemented in Canada in 2000, the average coding time per claim increased from 15 minutes to 33 minutes and turnaround time jumped from 69 days to 139 days.3
Your coders will need new coding books for ICD-10: Volume 1 is a tabular list of medical conditions; Volume 2 is an instruction manual; and Volume 3 is an alphabetical list of diagnoses. Our ICD-9 codes are 3 to 5 places, whereas ICD-10 codes are 3 to 7 places (Table).4 We are used to the majority of ICD-9 codes being numeric; however, ICD-10 codes are all alphanumeric and begin with a letter and end with a numeric code indicating laterality of condition when appropriate. The right side is indicated by a character 1, the left by character 2, and a bilateral condition by character 3. In addition, ICD-10 includes expanded injury codes and the creation of combination diagnosis/symptom codes that reduce the number of codes needed to fully describe a condition.
It gets much more complicated in that ICD-10 codes can be up to 7 characters in length, and when used to bill for injuries they end with a letter used to identify the encounter type. The letter A indicates initial encounter; D indicates a subsequent encounter; and S indicates a sequela encounter. For many injury codes, a “dummy” placeholder will need to be used to expand the code to 7 characters. For example, S06.0x1A is used to code for “concussion with loss of consciousness of 30 minutes or less initial encounter.”
Documentation of injuries will need to describe the injury, including laterality, and whether the visit is the initial encounter or subsequent encounter. In addition, you must identify the cause of the injury (ie, struck by car), where it occurred (near the patient’s school), and what activity the patient was doing (ie, crossing the street). In cases of concussion, we need to include whether there was loss of consciousness and the duration of the loss of consciousness. We need to indicate if a condition is acute or chronic and any external factors that are related to the condition (ie, tobacco smoke exposure in case of otitis media).
In the case coding for a well-child exam, we need to indicate whether there was an abnormal finding (Z00.121) or not (Z00.129). In documenting an encounter for otitis media, providers should document type of infection (serious, suppurative, allergic); infectious agent, if known; chronicity (acute, recurrent, chronic); left or right side or bilateral; and if there is a rupture of the tympanic membrane. Also document if there are any contributing factors, such as tobacco smoke (see Figure 1).5 Note that if our documentation is inadequate, we may be subject to denied claims or even paybacks when audited by insurance companies.
Figure 2 shows a typical pediatric visit with comparison ICD-9 and ICD-10 codes.6 Some of our present ICD-9 codes “map” without modification to similar codes that we will use after the transition. Others do not map well at all. A recent study of Medicaid pediatric patients in Illinois looked at a total of 2708 diagnosis codes used by pediatricians in a total of 174,500 patient encounters. The study demonstrated that 26% of pediatric ICD-10 diagnosis codes are convoluted (complex mapping), which represents 21% of Illinois Medicaid pediatric patient encounters and 16% of reimbursement. The researchers recommended that pediatricians receive adequate training for the ICD-10 transition to prevent negative financial consequences.7
Fortunately, there is much information available via the Internet that will assist you and your staff in transitioning to ICD-10. Get your coders trained and ready to implement the new code set. Update your office superbills as well as your EHR. There are many inexpensive online courses you can take to prepare for the transition (see ”Online ICD-10 resources for physicians).
In researching this article, I learned that athenahealth, provider of a popular EHR, guarantees its customers that if any of a practice’s payers do not pay in a timely fashion following the ICD-10 conversion, it will advance cash to that practice against its outstanding claims. This is a reassuring promise. If you are unhappy with your present system, it might be worth considering athenahealth’s EHR or other vendors that will match this guarantee.
1. Hartley C; Physicians EHR; Nachimson Advisors LLC. The Cost of Implementing ICD-10 for Physician Practices-Updating the 2008 Nachimson Advisors Study, Available at: http://docs.house.gov/meetings/IF/IF14/20150211/102940/HHRG-114-IF14-Wstate-TerryW-20150211-SD001.pdf. Published February 12, 2014. Accessed February 17, 2015.2.
2. Weems S, Heller P, Fenton S. Results from the Veterans Health Administration ICD10CM/PCS Coding Pilot Study. Paper presented at: ICD10-CM/PCS and Computer-Assisted Coding (CAC) Summit, Washington, DC; April 22, 2014.
3. American Association of Professional Coders (AAPC). ICD-10: The History, the Impact, and the Keys to Success. Available at: http://www.aapc.com/icd-10/icd-10-white-paper.aspx. Accessed February 17, 2015.
4. Centers for Disease Control and Prevention. International classification of diseases, (ICD-10-CM/PCS) transition. Available at: http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm. Updated November 5, 2013. Accessed February 17, 2015.
5. ICD-10-CM tabular list of diseases and injuries. Available at: http://cdn.roadto10.org/wp-uploads/2014/08/2015-ICD-10-CM-Tabular-List-of-Diseases-and-Injuries.pdf. Accessed February 17, 2015.
6. Centers for Medicare and Medicaid Services. Road to 10: The Small Physician Practice’s Route to ICD-10. Pediatrics Clinical Scenarios. Available at: http://www.roadto10.org/action-plan/phase-2-train/clinical-scenarios-pediatrics/#1_1. Accessed February 17, 2015.
7. Caskey R, Zaman J, Nam H, et al. The transition to ICD-10-CM: challenges for pediatric practice. Pediatrics. 2014;134(1):31-36.
The Centers for Medicare and Medicaid Services has some outstanding materials, including webcasts and coding examples:
American Health Information Management Association (AHIMA) offers a variety of resources for ICD-10 implementation:
American Association of Professional Coders (AAPC) also features a variety of ICD-10 online resources:
Websites for ICD-10 training courses:
Clinical Documentation for ICD-10 Training, online program, $250
ICD-10 Documentation Training for Physicians, online course, $395
World Health Organization (WHO):
ICD-10 Interactive Self-Learning Tool, free http://apps.who.int/classifications/apps/icd/icd10training
Abbreviations: ICD, International Classification of Diseases.
Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.