A Weightier ICD-10 — Is the Industry Ready for the First Round of Updates?
By Katie Sutton, RHIT, CCS
The all-important transition to ICD-10 has come and gone, and early indicators suggest that the industry crossed the finish line satisfactorily. Years of preparation and planning appear to be paying off as health care organizations absorb the mammoth code set—with five times as many codes as its predecessor—into their clinical and financial systems.
While the proverbial pat on the back has certainly been earned, it's important that stakeholders resist the temptation to let their guard down. Five years have passed since any updates have been introduced to ICD-10. A gift to health care organizations to ease the complexities of navigating the transition from ICD-9, the grace period has now ended, and 2016 is expected to usher in a sizeable first round of revisions and additions.
The industry is fully aware of ICD-10's reach into nearly every aspect of clinical and financial operations. Introducing a large set of updates will once again require readiness strategies from vendors, providers, and payers. Specifically, hospitals and health systems need to ensure systems and workflows support clinical integrity, efficient revenue cycle, and operational effectiveness.
The Updates Are Coming
Beginning October 1, 2016, the annual update cycle for the ICD-10 code set will resume. A March review of proposed changes to both ICD-10-CM and ICD-10-PCS by the ICD-10 Coordination and Maintenance Committee yielded recommendations for new code descriptions, but no final decisions.
Current proposals point to the potential introduction of a whopping 5,550 revisions to ICD-10-CM and ICD-10-PCS in the October update. As such, the fiscal year 2017 classification systems would grow to a total of 75,625 PCS codes, including approximately 3,650 new codes. Approximately 1,900 new ICD-10-CM codes would also be introduced along with nearly 500 revised ICD-10-PCS codes and 351 revised ICD-10-CM codes.
New PCS codes primarily reflect changes to cardiac devices, the addition of bifurcation as a qualifier, additional body parts, and congenital cardiac procedures and placement of an intravascular neurostimulator. In fact, 97% of PCS codes are cardiovascular related.
In contrast, changes to ICD-10-CM cover a wider range of body systems and code book sections, increasing specificity to elevate patient care. For instance, proposed codes for blindness and low vision expand the detail used to track sight loss. The full list of the proposed new ICD-10-CM codes, as well as additions and deletions, can be viewed at the Centers for Disease Control website.
Is the Industry Ready?
The 2016 update is the first large update to be considered for ICD-10, but it certainly won't be the last. In truth, industry professionals have long recognized that there are gaps throughout the procedure and diagnosis sections that must be addressed.
Effective response to current and future updates requires strategic positioning by health care organizations. While the scope of preparations will not match that required for the ICD-10 transition, the same framework for success will still be needed for ongoing readiness. Health care organizations will need to consider resource allocation, training, clinical documentation improvement (CDI), and financial analysis.
CDI will remain a focal point of ICD-10 success to ensure providers are addressing the specificity required for accurate coding and optimal reimbursement. Financial analytics is a critical component of identifying potential areas of risk and documentation improvement needs. New codes can result in higher or lower reimbursement, and health care organizations must be aware of vulnerabilities to effectively respond. For example, specificity is key in ICD-10. By correctly coding gastrointestinal stromal tumor of the esophagus (C49.A1) rather than the unspecified code of gastrointestinal stromal tumor, unspecified site (C49.A0), reimbursement will increase.
Addressing Unspecified Codes
ICD-10 experts have continually cautioned health care organizations that overuse of unspecified codes creates a liability that must be addressed. While currently allowed by the Centers for Medicare & Medicaid Services, use of many of these codes will be eliminated at the same time the ICD-10 update is occurring. Health care organizations will need to allocate resources for staff training to avoid fallout associated with lower reimbursements and lost revenue opportunities.
Organizations with access to significant IT resources are best equipped to deploy these ongoing, comprehensive internal strategies, but the question becomes: Is it the best use of their time? On the other hand, most resource-strapped hospitals will need extra help to effectively respond. The good news is that there are automation and software tools already on the market that can speed execution of analytics strategies as well as provide mapping capabilities to streamline system remediation efforts and enterprise terminology management.
The right solution can analyze diagnosis-related group shifts, filter by greatest impact, understand the root, and perform "what-if" analysis. Armed with this information, health care organizations can pinpoint CDI opportunities and conduct revenue impact analysis by payer, provider, and service line.
The detail afforded by ICD-10 is a major step forward, but the code set still has miles to go before it meets industry expectations. Going forward, stakeholders can expect ongoing large updates—some much bigger than others—that further advance health care's pursuit of better care delivery. The final code updates with the 2017 addendum are expected to be published in June, ahead of the October implementation date.
— Katie Sutton, RHIT, CCS, is clinical informatics manager with Health Language, part of Wolters Kluwer Health, and an ICD-10 approved trainer.