Pediatric Coding Alert

Think we should just ‘wait for ICD-11?’ Here’s why you can’t.

As we mentioned in the last issue of Pediatric Coding Alert, the ICD-10 implementation date has been moved back by at least a year. Although CMS has not yet announced the new effective date, you know that you have at least until Oct. 1, 2015 to adhere to the ICD-10 requirements. However, that doesn’t mean you should forget about it. In fact, most coding experts encourage practices to use this opportunity to take the extra time to prepare appropriately for the new diagnosis coding system.

If you’re facing complaints from doctors who are still dragging their heels before they learn the ICD-10 system—or those who refuse to learn it because they’re thinking it will be pushed back again or eliminated altogether—then  turn to the following six answers provided by Joe Nichols, MD, a member of CMS’s ICD-10 Task Force, during the agency’s “ICD-10 Clinical Documentation” webinar, which took place on March 19.

Complaint 1: “There are way too many new codes to learn.” 

Response: ICD-10 code additions vary widely per specialty, Nichols said. “There are some areas where we see a very substantial increase in the number of codes, and some areas where the codes actually go down,” he said.  “So if you look at an area like fractures, that’s probably the biggest increase in the number of codes, which goes from about 747 codes under ICD-9 for fractures up to about 17,000 codes under ICD-10.” 

If, however, you look at mood related disorders, there are fewer codes under ICD-10 than ICD-9. “On the behavioral health side, there really has not been a substantial increase in the number of codes, and many of them map one-to-one,” Nichols said. “Hypertensive disease and end-stage renal disease have half the number of codes under ICD-10 than under ICD-9.”

Therefore, whether or not you have to face a huge number of new codes will depend on your specialty. If, however, you are in a field where the number of codes has increased, you shouldn’t have to change much about the way you document, he added. 

“If we look at why there are so many additions, for instance in the number of fracture codes, there are about 2,466 femur fracture codes,” Nichols said. “That doesn’t mean we’ve suddenly discovered thousands of additional ways the femur can be fractured, it just means we’ve added different information to each type of fracture.” For instance, one third of the codes are exactly the same as they were under ICD-9, they’ve just been expanded to have specific codes for right side versus left side in the diagnosis codes, he said.

As a pediatric example, Nichols said, suppose a patient presents with otitis media. The code selected under the H65-H66 series will depend strongly on the additional factors that may have affected the case of OM, “such as which side is involved, whether it’s bilateral, or whether there were environmental factors that impacted the OM—was there a relationship between exposure to environmental tobacco smoke by the patient? Was it a recurring condition? Acute or chronic? What complications, such as rupture of the tympanic membrane, took place? Did it manifest as purulent or suppurative drainage?” he asked. “These are all now captured in the codes, whereas they didn’t used to be,” he said.

In addition, if a patient has measles complicated by otitis media, you’ll report B053 under ICD-10, but if he instead has influenza with otitis media, the code will instead be J1183. 

Complaint 2: “ICD-10 won’t help me clinically take care of my patients.”

Response: Although physicians may not feel like the ICD-10 code set will make patient care any different, that’s not necessarily the case. “We have to think broader than that,” Nichols said. “Healthcare crosses a boundary of time and providers. That patient is going to see someone else over time and will have different conditions…and as clinicians we really should try and be leaders in the industry to provide accurate data and analyze what’s happening in healthcare.”

Complaint 3: “ICD-10 isn’t relevant to me because I’m on the outpatient or professional side and I don’t get paid based on diagnosis codes.”

Response: “Even in ICD-9, we have codes that factor into payer processing rules in terms of the determination of appropriateness, measures of quality, pay for performance, compliance, and contracting decisions,” Nichols said. Although payment is not specifically tied to the diagnosis code, these codes have always been important from a business perspective.

However, “as we move into ICD-10 and toward a new accountable care, value-based purchasing environment, diagnosis codes will factor more and more prominently into different changes in reimbursement models that are being proposed within the industry today,” he said. “A lot of these reimbursement models aren’t looking just at what was done, but why.” Therefore, even if your payments aren’t tied directly to your diagnosis codes right now, that could change in the future.

Complaint 4: “We should just wait until ICD-11 comes out.”

Response: Although this is a common pushback, it isn’t reasonable, Nichols said. “ICD-11 is not slated to come out until 2015, and if we look at the historical implementation and just do the math, it could be 2039 before we see ICD-11 implemented, given the history of how we’ve implemented the codes in the past,” he added. “We’ve got a code set that’s already 30 years old—we can’t wait another 30 years to move forward.”

Complaint 5: “We should go directly to using SNOMED for diagnosis coding.”

Response: SNOMED-CT (which stands for Systematized Nomenclature of Medicine – Clinical Terminology) is more clinically focused, but was never designed to be used for disease classification, Nichols said. In addition, SNOMED is even bigger than ICD-10, with over 300,000 codes. “Many of the stakeholders in the industry really are not familiar with SNOMED,” Nichols added. “I believe SNOMED coding is actually even more complex than ICD-10.”

Complaint 6: “Some of the ICD-10 codes—such as ‘hit by spacecraft’ or ‘suicide by paintball gun’—are just a waste.”

Response: The reality, Nichols said, is that we’ve always had these types of codes, even in ICD-9. “The two codes above [regarding the spacecraft and the paintball gun] are actually ICD-9 codes,” Nichols said. “So while we have a lot of codes that may not make sense to some people, maybe something like ‘hit by spacecraft’ makes sense if you’re trying to track injuries for NASA employees,” he said. We really don’t even pay any attention to these codes if they’re not relevant to us, so we should ignore the ones we don’t deem important, he added.