Tuesday, September 29, 2009

Preparing for ICD-10

In 2013, CMS will require the use of ICD-10 for coding of diagnoses in billing/administrative transactions. The code set allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion of the 17,000 codes available in ICD-9. How can we best prepare for this transition?

1. Improve electronic clinical documentation

The granularity of ICD-10 requires precise clinical documentation. Unstructured paper-based notes are unlikely to enable coding beyond the most general code for each diagnosis. ARRA incentives require ambulatory EHR implementation with structured problem lists, medication management, and clinical documentation as well as hospital CPOE use. These electronic systems will provide the foundation for the detail needed by billers/coders to accurately select the most specific diagnoses.

Here's an example - in ICD-10-CM, the code L89.133 is for a pressure ulcer of right lower back, stage 111. This single code in ICD 10 is specific to the right lower back and stage. Detailed electronic clinical documentation is needed to select the right code.

2. Train HIM professionals

The American Health Information Management Association (AHIMA) is the leading advocate for ICD-10 and training HIM professionals.

Here's an example illustrating the training needed:

The ICD 10 code for Pathological fracture, right radius, initial encounter is M84.433A. This code is specific as to the location of the fracture, including laterality. The seventh character extension identifies the episode of care. Separate code categories are available for pathologic fractures specified due to a neoplasm or osteoporosis.

3. Embrace SNOMED-CT

Meaningful Use specifies ICD9 or SNOMED-CT for problem list management in 2011, ICD10 or SNOMED-CT for problem list management in 2013, and SNOMED-CT for problem list management in 2015. SNOMED-CT enables a clinician to document signs/symptoms, rule-out diagnoses, and problems, not just diagnoses. The structured clinical observations embodied in SNOMED-CT encoded clinical document will facilitate the accurate coding of ICD-10 diagnoses. The NLM's SNOMED-CT Core Set will include an ICD-10 crosswalk in the future.

4. Ensure we have the right vocabulary tools

Just as with the NLM SNOMED-CT Core set, it's important that the country has easy access to ICD9-ICD10-SNOMED-LOINC mappings that enable fluid translation of one codeset to another for various purposes. Many companies are working on such resources such as

Intelligent Medical Objects, which provides such services inside the EPIC EHR

AnvitaHealth (disclosure: I serve on the Board) which provides such services to Google Health

Apelon which has provided terminology services to Intersystems, Intel and the New Zealand Ministry of Health.

SNOMED Terminology Solutions not only maintains SNOMED CT on behalf of the IHTSDO but also provides mapping and consulting services to help provider organizations, vendors, various agencies of HHS, and other HIT-related companies with the successful implementation of terminology standards.

Over the next year, the HIT Standards Committee Clinical Operations Workgroup will discuss the vocabulary tools needed to support meaningful use.

5. Work with vendors to ensure EHRs and Hospital Information Systems are capable of supporting ICD-10 and X12 5010.

Existing EHRs and HISs will need to be upgraded to support ICD-10 coding and the transmission of transactions to payers via X12 5010 (replacing 4010). Vendors will provide one piece of the puzzle - software that is capable of supporting the new standards. Vendor efforts need to be supplemented with all the other strategies mentioned above to ensure successful ICD-10 implementation/meaningful use.

I realize that the dual transition of ICD-10 and SNOMED-CT over the next 5 years seems daunting. In my view, embracing SNOMED-CT for clinical observation encoding as part of electronic documentation provides the foundation for ICD-10 implementation by providing the clinical detail needed by billers/coders to accurately select the proper ICD-10 code. If we think of SNOMED-CT as the clinician facing vocabulary and ICD-10 as the administrative billing vocabulary for HIM professionals, adopting both codes is part of a single project plan to enhance the quality of healthcare data for all stakeholders.


Lyle said...

"Train HIM Professionals" should be expanded to "Train HIM Professionals, Physicians, Nurses, Payer Workers, Government Employees, etc. etc. etc." Our ability to interoperate with ICD9 codes is not only buying the same lists and books, but the collective experience of the entire industry agreeing on the proper activity and documentation for a specific code. Moving to I10 throws a lot of experience away as we start new and revise all the manuals, contracts, and accumulated research data.

This is not an argument against the change - it is necessary. But a warning that the amount of work is underestimated by those mandating it, especially considering the moving target of medical science against a slower moving code set and the to-be-seen ill defined areas of the new code sets.

Anonymous said...

I am new to your blog and look forward t reading more

Thank you for a good introduction to ICD10s.


Dan said...

I like the idea of snomed ct for representing clinicl precision. Then ICD-10's purpose in life is for billing. But do we really want/need more precision for billing? Will it be used to deny claims, count figures operated on, etc.? I think this makes billing more complicated which is going in the wrong direction.

I realize that the rest of the world uses ICD10 and the change will happen. I would hope that for billing though a coarser grained subset might be the best approach.

April Harned said...

Thanks for the great post highlighting the challenges of the ICD transition. I work for Progress DataDirect, a leading data integration vendor. We've recently made available a HIPAA/ICD-10 Upgrade Toolkit featuring generic mappings to help developers jump-start their HIPAA 4010, 5010 and ICD-10 data conversions. We hope you’ll check the toolkit out here: http://blogs.datadirect.com/2009/09/datadirect-hipaa-icd-upgrade-toolkit.html