Where were you when you first learned about ICD-9?

ICD-9-CM has been around since 1977, and was implemented in the U.S. in 1979. If you have been in healthcare since that time, you remember when ICD-9 was new and exciting. If you have any old ICD-9 coding books you can see how the changes in the past ten years have increased the number of available codes, and required you to keep on top of your coding skills.

Remember when CMS was HFCA (and do you still slip up and call them HCFA?)? We have been hearing about ICD-10 for several years now. Hold on folks, it looks like more change is on the way!

But, is it the right change at the right time?

On August 22, 2008, the Department of Health and Human Services (HHS) published the proposed changes to the HIPAA Transaction and Code Set Rules. These changes will eliminate use of ICD-9-CM as the standard code set! October 1, 2011 would be the date where we could start using ICD-10-CM for reporting diagnoses. Check out the Federal Register web site and search for 73 Fed. Reg. 49796 for the details of the proposed rule. Unlike HIPAA implementation, there are no staggered dates, which mean all organizations, including those classified as "small" and "large" will all have to comply on the same date.

The HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS, states:
"This proposed rule would modify two of the medical data code set standards adopted in the Transactions and Code Sets final rule published in the Federal Register. It would also implement certain provisions of the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Specifically, the proposed rule would modify the standard code sets for coding diagnoses and inpatient hospital procedures by concurrently adopting the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding. These new codes would replace the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Volumes 1 and 2, and the International Classification of Diseases, Ninth Revision, Clinical Modification (CM) Volume 3 for diagnosis and procedure codes, respectively."

What's in store for us as coders?
ICD-10-CM increases the number of diagnostic codes to 68,000 codes from approximately 13,000 codes in ICD-9.
Around 87,000 ICD-10-PCS codes will be required for inpatient coding.
The ICD-10-CM codes are up to 7 characters in an alpha-numeric system and provide more specificity than ICD-9-CM codes.

HHS believes the benefits of ICD-10 include:

• The ability to handle new codes more timely.
• Potentially fewer improper and rejected claims.
• Disease management tracking with more precision.
• Parallel disease monitoring worldwide by using ICD-10 codes.

"The AAPC agrees that ICD-9-CM is inadequate for the future and ICD-10-CM offers desirable benefits. It is important to recognize that to achieve these benefits, the correct code MUST be selected every time."

As with any change, there are risks and benefits. The risks of problems include: 

• The potential for an increase in unpaid or improperly paid claims.
• Financial impacts to an already burdened healthcare system.
• A strain on healthcare as providers we try to guide them through another change in their coding and compliance functions.  

The question is: can we implement ICD-10 without bringing the U.S. healthcare system to a halt?
The ICD-9 Coordination and Maintenance Committee meetings are held twice a year at CMS in Baltimore in March and September. The Coordinating Parties are the leaders who maintain ICD-9. The attendees were:

• American Health Information Management Association (AHIMA), represented by Sue Bowman, RHIA, CCS
• American Hospital Association (AHA), represented by Nelly Leon-Chisen, RHIA
• Centers for Medicare and Medicaid Services (CMS), represented by Pat Brooks, RHIA
• Centers for Disease Control (CDC), represented by Donna Pickett, RHIA

What did this group have to say about the ICD-10 implementation at the September 24 and 25 meetings?

A history of ICD-9, along with a list of the system flaws, was presented by Brooks. The shortcomings of the ICD-9 system have been discussed at these meetings for several years. The current system is filling up quickly, and in many areas it doesn't allow for specifics such as if the patient is being treated for an initial, subsequent, or late effect of an illness or injury.

Benefits discussed by Pickett provided more information on the details of the ICD-10 code structure. The major differences were reviewed, providing examples of the major modifications that will take place such as adding trimesters to obstetrical codes. ICD-10 has been available for use since 1994, and has been implemented in various countries since 1995.

AHA planed to continue its functions with publications similar to Coding Clinic for ICD-9-CM. Leon-Chisen provided information on implementation planning and the AHA's past role in field testing of ICD-10, and its future role in coder education. The presentation included a laundry list of hospital implementation issues.

Bowman, the AHIMA representative, indicated that there is still no clear answer on coder education requirements to maintain credentials or if additional testing will be needed. However, academic preparation is under way for the impacts to the AHIMA college degree curriculums. Start planning for education phase-in now, but not too soon  the recommended time frame discussed was three to six months.

Physician presenter Jeffrey Linzer, MD, FAAP, FACEP, commented that he supports the "greater granularity" of ICD-10 to promote quality patient care. Dr. Linzer provided the example of a pediatric patient who is seen for recurrent ear infections. Current ICD-9 nomenclature does not allow him to know which ear has had the infection, or if both ears are involved.

Mapping of ICD-10 to ICD-9 is currently being maintained by 3M, whose representative, Rhonda Butler, provided an update on the conversion at the meeting. The GEMs, or General Equivalence Mappings, find and replace diagnosis codes to convert MS-DRGs. The report provided by Butler indicated that GEMs can replace the codes with 95% accuracy. However, a single ICD-10 code can possibly translate into more than one ICD-9 code.

Some good news: no changes to MS-DRG's will occur for several years after ICD-10 implementation in to allow an adjustment period. A sample of the conversion was provided at the meeting, with the goal to convert the rest of the MS-DRGs in one year, subject to the final rulemaking. A question was asked from the floor regarding the suspension of the addition of new codes for a year before I-10 implementation  this would have to be a request made through the proposed rule in the Federal Register  Document CMS-2008-0096-0001. 

What else happens at the meetings?

Particularly on the first day of this event, physicians, device manufacturers, and researchers attend the meeting to support their needs for new Volume 3 codes. On the first day, presenters provide clinical and statistical information about new technologies, and take questions from both clinicians and coders regarding the proposed changes and additions.

On the second day, diagnosis code requests are reviewed. No reimbursement issues are discussed at these meetings.

Who can attend?

It is important to point out that anyone can attend these meetings  this is a public forum. Registration is online and is available about one month before the events. You can sign up for one or both days, and attendance is free. CEU's are available from AAPC and AHIMA.

December 5, 2008 is the deadline for submission of public comments on the proposed rule revisions discussed at the September, 2008 meetings for code implementation October 1, 2009.

Special deadline: LITT The deadline for public comments on the proposed code addition for the new procedure for special April 1, 2009 implementation was October 10, 2008. The meeting discussion regarding mid-year implementation was short and to the point: Jeanne Yoder, MPA, RHIA, CPC, CPC-I, CCS-P, remarked that unless the reasons for adding new codes mid-year was related to a public health concern or truly breakthrough technology, the enormous costs of adding new codes mid-year would outweigh the possible benefits.  Others in the audience agreed with Yoder's comments. When asked for further comments after the meeting, Yoder elaborated on the burden of changes to multiple computer systems, as some systems

You can find more information online:

The summary report of the Procedure part of the September 24 and 25, 2008 ICD-9-CM Coordination and Maintenance Committee meeting is posted on the CMS site at http://www.cms.hhs.gove/ICD9ProviderDiagnosticCodes.

The summary report of the Diagnosis part of the September 24 and 25, 2008 ICD-9-CM Coordination and Maintenance Committee meeting report will be posted on the NCHS site at http://www.cdc.gov/nchs/icd9.htm.

BY: Tina Cressman, MALS, CPC-I, CPC-H-I, CPC-P, CCS-P, MCS-P, MCS-I, CMC
Director, Managed Care Education
Cooper University Hospital
3 Executive Campus, Suite 390
Cherry Hill, NJ 08002
Telephone: 856-382-6574
Fax: 856-382-6590
Chair, MSNJ Medical Practice Manager's Section