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February 11, 2013

ICD-10’s Heavy Footprint
By Susan Chapman
For The Record
Vol. 25 No. 3 P. 16

Everyone knows ICD-10 will redefine the coding profession, but providers and patients also will feel its power.

A means to classify and track diseases and a mechanism for data collection and reimbursement, the International Classification of Diseases (ICD) has experienced many changes over the years. Way back in 1994, its 10th incarnation came into use in most of the world’s industrialized nations. However, the United States was not among those hopping on board with the new codes, instead opting to wait 20 years before joining the rest of the crowd.

As the October 2014 deadline to implement ICD-10 approaches, many sectors of the healthcare industry are feeling the pinch. In the HIM world, coders likely will take the brunt of ICD-10’s force. Beyond that, expect the new codes to have a profound effect on physicians and patients.

Impact on Providers
The transition from ICD-9 to ICD-10 will bring with it a vast increase in codes that will greatly affect physicians. “Every physician, but particularly physicians in hospitals, will be impacted,” says Dianne Haas, PhD, RN, head of the consulting services division at TrustHCS. “There are about 15,000 ICD-9 codes and 155,000 ICD-10 codes, more than an eightfold increase. Physicians in hospitals will need to work in a highly collaborative way with HIM and CDI [clinical documentation improvement] staff to learn about the changes in the code sets and how they will impact the nature of their documentation.”

It will take a team effort to get physicians up to speed, Haas says. “Hospital leadership, staff responsible for the EMR templates, IT, and many others will need to understand and support physicians and others as they grapple with required documentation changes,” she says. “An attitude of ‘we are all in this together’ will need to be assumed to move the entire organization to a successful ICD-10 implementation. And those who use data for meaningful use will be concerned about whether they are making their notes substantive enough to meet the documentation requirements as well as the multiple other quality, privacy, coordination, and data sharing goals of meaningful use.” 

ICD-10 incorporates greater specificity, clinical data, and information relevant to ambulatory and managed care encounters, says Deborah Robb, BSHA, CPC, an AHIMA-approved ICD-10-CM trainer and director of physician services at TrustHCS. “In addition, the structure of ICD-10 allows for the possibility of greater expansion of code numbers. This classification will also extend beyond simply the classification of disease and injuries to include risk factors that are frequently encountered in a primary care setting,” she says. “The new system also includes those diseases discovered since the most recent revision of ICD-9. General terminology as well as disease classification has been updated to be consistent with accepted and current clinical practice.”

The tremendous increase in coding options could prove to be a royal pain for physicians, says Todd Rothenhaus, MD, chief medical officer for athenahealth. “ICD-10 permutations of codes will be an explosion. There could be, for instance, four or more codes for what now has only one code in ICD-9,” he notes. “To further illustrate, a forearm fracture, which was one code, now becomes which bone, which visit, etc, and physicians will need to indicate these distinctions.”

Because of the exponential growth in codes, there is concern about how physicians will adapt to the new system. Charles Sawyer, MD, assistant chief medical information officer at Geisinger Health System in Pennsylvania, explains that physicians likely will view the move to ICD-10 as something that will create additional work without any corresponding increase in reimbursement.

“It’s expected that there will be a 20% increase in the time required for physician documentation to produce the specificity required in ICD-10,” he says. “Since the additional granularity will be of very little day-to-day benefit to physicians, this will likely be viewed as just another regulatory requirement. The variation in disease specificity in ICD-10 is much greater than that required to provide clinical care to patients. Therefore, from the practitioner’s point of view, the transition to ICD-10 is all cost with little benefit. Claim processing requirements may force physicians to utilize ICD-10 codes, but embracing ICD-10 is an unlikely short-term expectation.”

To further complicate matters, Rothenhaus points out that the government also is moving physicians to SNOMED CT, which provides a standardized clinical healthcare terminology. “SNOMED CT describes every disease people can have, and physicians must use it to conform to meaningful use,” he says. “The problems, risks, and diagnoses are different but similar. This portends a coding Armageddon, which is being mandated by the government and creating an enormous challenge.”

Rothenhaus says how well physicians deal with the changes may depend on whether they are using an EHR. “Offices that still use paper will have a more challenging time making the transition,” he says. “But physicians shouldn’t have to consider all this; this is back-office work. We need to protect the physician, who is a living revenue generator.”

ICD-10 will affect certain specialties more than others. “Orthopedists, obstetricians, cardiology—where cardiologists, for instance, will need to be specific as they identify each vein—will be particularly impacted,” notes Debra Primeau, MA, RHIA, FAHIMA, president of Prime Health Consulting, adding that while virtually everyone in healthcare must have at least some knowledge of the new codes, physicians will have to be well versed within their own specialties and have a broad-based understanding of the philosophy behind ICD-10. “Through education, physicians need to understand how documentation has implications beyond their respective areas of service. They need to be mindful of how it impacts physician profiling, for example, where public data that are the culmination of information that enables patients to select physicians and what role this plays in quality metrics.”

Other factors make it imperative that physicians document with a sharper focus. “Reimbursement is at stake,” Primeau says. “ICD-10 allows you to have much greater specificity over ICD-9, which enables us to have a more complete record. Physicians will have to supply more information on the cases they’re treating. Not only does this make a difference in reimbursement, but it also should lead to better healthcare overall.”

Robb agrees: “The expanded degree of specificity should provide more detailed information, which would assist providers, payers, and policy makers in establishing appropriate reimbursement rates, improving the delivery of healthcare, improving and evaluating the overall quality of patient care, and effectively monitoring both service and resource utilization.”

While it will be difficult for physicians to embrace ICD-10, Robb believes by helping them understand the dynamics of the new code sets and the level of specificity required, the transition will go smoother. Also, physicians who comprehend the processes and support the necessary changes can encourage others to be more receptive to ICD-10.

Impact on Patients
While possibly not as dramatic, ICD-10’s effects also will be felt by patients. “I suspect patients will not notice a difference in the clinical care they receive, but they may have issues with claims being denied by their health insurer after the transition,” Sawyer says. “The difference they’ll experience will likely be financial and administrative rather than a change in their care.”

Besides having claims rejected, patients could possibly experience delays in receiving laboratory or radiology services if the referring physicians do not provide the proper ICD-10 codes.

Because physicians must supply the diagnoses and utilize the new codes, patients likely will not be directly affected during office and hospital visits, Rothenhaus says. However, as the popularity of patient portals grows, consumers may see changes as they access and decipher their own medical records. “The way patient information is displayed may or may not be in ICD codes. Code changes and text changes could mean that patients may see unusual things,” he says. “I’ve heard of situations where codes convey a somewhat different diagnosis for a patient than what was told to them by the physician. This can be cause for concern as patients translate the medical record for themselves.”

Citing the incongruity between SNOMED and ICD-10, Rothenhaus says strange medical terms could send patients into a bit of a panic. “A patient might receive a diagnosis of hip pain. In ICD-9, it is called ‘enthesopathy of hip region.’ If you don’t know what this is, it could sound a little scary. In ICD-10, the code is ‘trochanteric bursitis.’ This incongruence of terms means that patients may need a universal translator, but there is no magic decoder,” he says.

Rothenhaus adds that physicians generally are uncomfortable when patients request their medical records. “So often physicians write notes that patients don’t understand or would take issue with. For instance, they may write ‘obese’ when patients don’t think they’re obese,” he explains. “A purely untranslated medical record is hard to swallow.”

Haas believes ICD-10 can have a positive impact on older and chronically ill patients. “Younger, healthy people likely will not realize much change because they generally consume healthcare resources infrequently and generally for health maintenance or short-term illness management,” she says. “Older individuals or those suffering from significant illnesses—for instance, those with cancer—may be more focused on learning more particularly what is being recorded in their EMR/EHR so that they are assured that their care is being well coordinated and that all their providers have a complete picture of their health status. The level of specificity that ICD-10 demands will ultimately help patients become more educated.”

The richness of the data generated by ICD-10 is bound to have a profound effect on the overall population’s health, Haas adds. “[The specificity] can have an enormous impact on public reporting of many types of health- and illness-related data,” she says. “That, in turn, can also impact and benefit patients.”

Mark Jahn, vice president of the healthcare practice at Atrilogy Solutions Group, believes ICD-10’s far-flung reach can’t help but influence care patterns. “Since ICD-10 will affect all hospital departments, any clinical step or part of the revenue cycle that touches a patient, such as eligibility, scheduling, admitting, patient care, and billing, could potentially have a profound impact on the type of care provided,” he says. “For instance, medical policy changes, which are certain to occur as a result of ICD-10, including what is or is not covered under each health plan, will undoubtedly impact patients.”

In the long term, Jahn envisions any changes to be beneficial. “In the future, as a result of ICD-10, explanation of benefits statements will likely look a little different and have more specific information than in the past,” he notes. “Eventually, patients should see more streamlined claims processing and less payment issues. Payers will make their claims adjudication and payment processes more efficient due to having more specific information to process the claims. Several years into the future, patients should see an improvement in care and outcomes, one of the main reasons why we are converting to ICD-10 in the first place.”

Serve Notice
A transition of this magnitude requires educating all parties involved. Physicians need to be aware of the new codes even if they’re only the ones for their own specialties. Patients may want to become more familiar with the changes to better understand why a claim was rejected. “Patients should be aware of the broad strokes,” Primeau says. “Hospitals may share information. As consumers become more familiar with EHRs, they become more familiar with codes and, as they see bills with more detail, they’ll question things more.”

It’s up to coders and CDI staff, the two groups probably most affected by ICD-10, to lead the educational charge. “In 2013, a robust, managed CDI will be a hospital’s best method for ensuring that physicians are being informed, supported, and educated about the documentation requirements being made of them in order for the record to be coded to the highest level of specificity,” Haas says. “As we move toward ICD-10, coders and CDI specialists must work and be trained together and partner with physicians. They have to analyze forms, revisit queries, and be actively engaged in a learning process that will ultimately impact the entire organization.”

Extended staff also must be part of the education process. Haas says initiatives such as hanging educational posters and creating pocket-sized informational cards are examples of tools that help raise ICD-10 awareness. “Organizational leadership must accept responsibility for the transition and know what its role is in ensuring that everyone is aware and ready,” she says.

— Susan Chapman is a freelance writer and author based in Los Angeles.