May 7, 2012

Is ICD-10 the Holy Grail for Disease Management?
By Marybeth Regan, PhD
For The Record
Vol. 24 No. 9 P. 24

Producing data richer than a triple chocolate layer cake, ICD-10 has the potential to boost the care and treatment of today’s most pressing health concerns.

The International Classification of Diseases (ICD), a complex scheme of classifying diseases, has been referred to as the link to international healthcare collaboration. Care and disease management—knowledge about disease causes, cures, and optimal treatment patterns—is an international pursuit void of political boundaries and bias. For example, global adoption of ICD-10 could have more quickly determined the expansion and impact of the West Nile virus and severe acute respiratory syndrome (better known as SARS), leading to earlier detection and improved tracking.

Although it appears likely that the effective date for implementation will be pushed back one year to October 1, 2014, US healthcare regulators have mandated that every provider and payer organization institute ICD-10 codes. The order, which has been referred to as a tsunami of change and compared with the Y2K debacle, will be the only method for disease classification, standardized treatments, and international data sharing. It will also play a huge role in improving the accuracy of provider reimbursements.

Over time, the change should be well worth the cost for physicians, researchers, disease management organizations, patient-centered medical homes and, of course, patients. ICD-10 codes have a vastly greater level of detail than that provided by the current ICD-9 codes. ICD-10 will allow physicians to expect better matching of payment for their work effort, more accurate risk adjustment in any bundled payment system, and increased payments under pay-for-performance plans.

Disease Management
During an appointment, a physician collects patient information to formulate a diagnosis. ICD-10 codes are used to classify the identified disease, injury, and treatment. Each condition is identified under a unique category and a specific code. The codes used in ICD-10-CM are far more expansive (68,000 codes) than the current ICD-9-CM codes (13,000 codes). This greater degree of division results in better care and disease management. First, ICD-10 will identify people with a disease state that wasn’t or couldn’t be identified using ICD-9. Second, ICD-10–based outcome data will lead to better patient management of those with a certain disease.

The Care Continuum Alliance defines disease management as “coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care. Disease management emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies. Disease management also evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goals of improving overall health.”

ICD-9 codes define chronic disease states only in general terms. ICD-10 has the potential to create value for patients, providers, and payers through improved effectiveness by identifying medical trends and disease identification. These new codes will distinguish small variations to establish specialized groupings to aid healthcare workers and patients with the disease and coordinate a care management approach.

For example, the ICD-10 code set offers multiple divisions with groups for type 1 and type 2 diabetes mellitus and subclassifications that create a more flexible and informative code. ICD-10 also helps improve population identification and severity stratification. This specificity, combined with medical software, enhances researchers’ ability to more precisely track conditions, treatments, and outcomes associated with disease management.

Graphic 1 shows several of the major areas that have changed under ICD-10.

Diabetes
The seventh-leading cause of death, diabetes affects 25.8 million people in the United States (about 8% of the population). Another 79 million Americans suffer from prediabetes. ICD-9 classifies diabetes as only controlled or uncontrolled, which is misleading because once all the expenses of diagnosed, undiagnosed, and prediabetes are totaled, the disease costs the country a staggering $174 billion in direct and indirect costs.

The American Diabetes Association lists the following as diabetic complications:

• Blindness: Diabetes is the leading cause of new cases among adults.

• Kidney failure: In 2008, diabetes accounted for 44% of all new cases of kidney disease.

• Heart disease: Diabetes increases the risk of heart disease, death, or stroke by two to four times.

• Amputation: In 2006, about 65,700 nontraumatic lower-limb amputations resulted from diabetes.

• Neuropathy: Sixty percent to 70% of diabetics suffer from mild to severe nervous systems damage.

ICD-10-CM classifies diabetes mellitus with 318 different codes. These codes are expanded to include the classification of the diabetes and its manifestations. In ICD-10, the category of diabetes mellitus has been updated to reflect the current clinical classification of diabetes.

For example, the diabetes category differentiates type 1, type 2, and drug- or chemical-induced diabetes, and diabetes due to an underlying condition. One ICD-9 code for diabetes (250.61), identified as diabetes mellitus with neurological manifestations type 1 not stated or controlled, is represented by the following multiple ICD-10 codes:

• E10.40, Type 1 diabetes mellitus with diabetic neuropathy, unspecified;

• E10.41, Type 1 diabetes mellitus with diabetic mononeuropathy;

• E10.44, Type 1 diabetes mellitus with diabetic amyotropy; and

• E10.49, Type 1 diabetes mellitus with other diabetic neurological complications.

The reason for the large number of codes is that ICD-10-CM provides more specific information, as shown in Graphic 2. Because of this, there is more information for clinical management purposes, making it possible to identify diabetes sooner and begin tracking a patient’s current and future treatments.

Deeper Understanding of Noncompliance
New information on patient compliance and medication adherence will also be captured as part of ICD-10. While only one code in ICD-9 addresses these cases, the expanded ICD-10 codes capture the issues and reasons for noncompliance as well as for not taking the correct amount of a prescribed medicine in the proper time. This is an increasingly important area of new insight, as some 32 million Americans use three or more medicines daily, while 75% of adults are nonadherent in one or more ways, according to research conducted by The Polling Company for the National Community Pharmacists Association. As former Surgeon General C. Everett Koop, MD, said, drugs don’t work in patients who don’t take them.

In a recent poll of Americans aged 65 and older who use medications, researchers found that 51% take at least five different prescription drugs regularly, and one in four take between 10 and 19 pills daily. Among those using five or more medications, 57% say they forget doses compared with 51% among those who take fewer medicines, according to Med Ad News.

Also, a March study released by CVS Caremark found that nonadherence to doctors’ orders is raising healthcare costs a staggering $290 billion annually.

In ICD-10, additional codes will provide detailed information about the reasons behind noncompliance, such as a lack of financial resources. By having such data in hand, a decision can be made to determine whether paying for a taxi to help a patient make a doctor’s appointment or pick up a prescription would enable compliance and be a far less costly option than having him or her visit the emergency department.

Asthma
There is no cure for asthma, but it can be managed through appropriate prevention and treatment. More Americans than ever before say they are suffering from asthma, a genetic and potentially deadly condition that is one of the country’s most common and costly diseases.

Consider the following daily statistics available from the Asthma and Allergy Foundation of America:

• Thirty thousand people have an asthma attack.

• Five thousand people visit the emergency department due to asthma.

• One thousand people are admitted to the hospital due to asthma.

• Eleven people die from asthma.

Recent increases in asthma-related morbidity and mortality rates have resulted in a corresponding increase in the condition’s economic impact, but little information is available relating to the costs of asthma based on its degree of severity. However, the move to ICD-10 should help provide more granularity because of its ability to provide more detail on severity. In ICD-10, there is a higher percentage of the number of codes that are expanded by some type of severity. For example, even “intermittent vs. persistent” has an inherent level of severity built into that portion of the code.

In the 1992 International Consensus Report on Diagnosis and Treatment of Asthma, a one-year study, severity of illness was classified into mild, moderate, and severe. The average total annual asthma-derived cost was estimated at $2,879 per patient, with averages of $1,336 for mild asthma, $2,407 for moderate cases, and $6,393 in severe asthma.

At all levels of severity, indirect costs were twice as high as direct costs. A minority of severe asthmatics incurred some 41% of total costs. The asthma’s cost was surprisingly high and varied substantially depending on the disease severity.

In 2009, the National Heart, Lung and Blood Institute released a study that estimated annual expenditures for health and lost productivity due to asthma to be more than $20 billion.

Because ICD-10 codes identify disease conditions more specifically, providers will be able to take advantage of richer and more complete data. With the new codes, physicians will be better able to monitor disease progression and the requirements to keep it under control, which is not only good for the patient but also reduces costs for payers.

Pregnancy
Another example of ICD-10’s specificity is how it will break down pregnancy into trimesters. With this narrower focus, health plans can ensure members receive prenatal care and mothers-to-be are better monitored, helping decrease the number of preterm and low-birth weight babies.

Approximately one in every 12 babies born in the United States weighs less than 5 lbs, 8 oz, the threshold to be considered a low-birth weight child. The lifetime cost of healthcare for individuals born with such a disadvantage is as much as $500,000, according to statistics reported in The Baltimore Sun.

Implementing ICD-10
ICD-10 is generally regarded as being one of the biggest challenges facing today’s payers and providers. Though often seen as a compliance issue, forward-thinking organizations that embrace and plan for the change instead of merely being reactive will realize tremendous benefits from the changeover.

Given the wide-ranging impact ICD-10 will have on multiple departments and the supporting technology necessary to pull off the transition, planning a strategic implementation approach is critical. To get started on this path toward a competitive advantage, there must first be an understanding of how ICD-10 will reshape information systems, operations, medical policy, staff, rules, and processes. All stakeholders must realize compliance is not only about programming system changes but should also focus on redesigning business processes to benefit from ICD-10’s clinical detail that can improve data, leading to quicker patient identification, better outcomes, and faster payments.

A New Era
ICD-10 will support disease management in numerous ways, including the following:

• Screening: will be a major force in the early detection of disease;

• Prediction: better able to identify who is at risk;

• Disease identification: positively identify and confirm a disease, usually without other treatments;

• Treatment: can be identified or changed based on the results of testing; and

• Monitoring/compliance: chronicle treatment to ensure the regime is producing the expected outcomes.

The key is to use this new, improved information with analytics to both identify and manage disease. As the data become more widely available, the information garnered from the worldwide implementation of ICD-10 may very well be a holy grail for health systems everywhere. It is up to us to make those data actionable.

— Marybeth Regan, PhD, who specializes in ICD-10, care and disease management, clinical informatics, and analytics expertise, serves as a healthcare solutions professional for IBM Global Business Services.