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ICD-10: Why Do We Need to Change?
By Angie Dibble, RHIT

The mere thought of the transition to ICD-10-CM/PCS has the entire health care industry in a tizzy. Articles, white papers, debates, lobbying, and outright stomping their feet and saying no are just some ways the industry has questioned the switch in coding systems, from the outdated ICD-9 to the now-demonized ICD-10.

If you listen to all the rhetoric, the ICD-10 transition is equivalent to a coding apocalypse. Many wonder whether there is any real value in all this change. What good could possibly come from changing to ICD-10? After all, if you can code something in ICD-9, why spend the money to code it differently in ICD-10? They’re just codes, right?

Maybe a new view of the entire health care system will provide some perspective.

Did you know that the ICD code system was not created for payment purposes? Medical professionals have focused so closely on the financial entanglement among diagnoses, coding, and billing that they’ve forgotten what the codes were created for: tracking the incidence of morbidity and mortality. In other words, ICD was created to teach us about the human health population, not bill for it.

As health care professionals become better at diagnosing diseases, ICD-9 grows more inadequate as far as supplying additional useful data. The code set is too limited and hasn’t kept up with technology, new diseases, and advances in health care. Some areas of ICD-9 are specific, but others are so generic that the related codes aren’t useful.

Like ICD-9, ICD-10 wasn’t created as a reimbursement system. Actually, American physicians worked with the World Health Organization to make ICD-10 more clinically relevant than ICD-9. But just as with ICD-9, the United States has customized ICD-10 for use in this country and to provide clinical accuracy and specified data that serve to benefit both patients and providers. It’s structured to better capture disease specifics and can provide the data needed to give a true picture of a particular disease’s incidence. This, in turn, will provide the information needed to draw the right conclusions on the efficacy of treatment methods.

ICD-9 contains a couple codes for noncompliance situations: V15.81, Noncompliance with medical treatment, and V45.12, Noncompliance with renal dialysis. What do these codes indicate? Why the patient was noncompliant? How he or she was noncompliant? Was the noncompliance intentional, accidental, due to poverty, due to senility?

Ultimately, these codes say nothing, and therefore health care professionals learn nothing about a patient’s reason for noncompliance. Despite the data being aggregated together, they learn nothing about the patients in a particular population or from a particular disease population and their reason for noncompliance.

Consider this example: George has congestive heart failure (CHF). His physician prescribes a medication during an office visit to manage George’s CHF, along with a diet plan and information about other limitations the physician feels are important for George to understand to manage his condition. He nods in agreement and leaves the office.

A few weeks later, the physician’s office gets a call from a hospitalist at the regional medical center indicating that George has been admitted with acute CHF decompensation. As information was gathered, the hospitalist team determined George wasn’t taking his medications as scheduled. The hospitalists treat George, adjust his medications as needed, again explain the disease process and management, and discharge George to follow up with his physician a couple weeks later. Ultimately, the physician is a little disturbed at how his patient could have misunderstood the directions on his medication.

In a couple weeks, George is readmitted to the medical center with an acute-on-chronic CHF episode. After further study and some discussion, it seems George did not take his medications as directed since his discharge. Now both his physician and the hospitalist team are disturbed about how this could have happened since readmission for the same condition in such a short time doesn’t look good for the hospital or the physician.

Delving deeper into George’s last stay, it appears he was worried about his ability to pay for his medications, since he takes several for conditions such as diabetes, COPD, and hypertension. George’s family members reveal that George, who is in his 80s, doesn’t seem to understand directions and has appeared more confused in the last year since his wife died. Therefore, he wasn’t readmitted to the medical center because his physician failed to treat George properly; he was readmitted because he was noncompliant—not willful noncompliance but a kind that easily can be labeled in ICD-10:

• Z91.12, Patient’s intentional underdosing of medication regimen, with an additional digit of 0 for the specific reason: Z91.120, Patient’s intentional underdosing of medication regimen due to financial hardship.

• Z91.130, Patient’s unintentional underdosing of medication regimen due to age-related debility.

Putting It Into Practice
Hopefully, now you have a better understanding of why ICD-10 implementation needs to happen. How many Georges are out there, failing to comply with instructions from their physicians? If facilities collect better, more specific noncompliance codes on their patient populations, what can they learn about their community’s needs? For instance, are there numerous older adults like George who need help with medication scheduling to remain independent? Are certain diseases showing up repeatedly with specific noncompliance codes either in the outpatient clinic setting or as inpatient readmissions?

ICD-10 will be more detailed and precise. It will require a little more of physicians and nurses but even more of coders, clinical documentation specialists, and patient service representatives. The question is, will this system finally provide the detail needed to collect relevant, useful, precise data to help facilities key in on what most benefits patients?

Now that’s a coding apocalypse I am willing to prepare for.

— Angie Dibble, RHIT, is a clinical documentation improvement specialist at Watertown Regional Medical Center in Wisconsin.