ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10-PCS. Plenty of myths are also floating around and some of them fairly prevalent. One way to make sure the most recent ICD-10 implementation delay is the last ICD-10 implementation delay is to bust some of these myths.
Myth 1: ICD-10 includes too many codes
Plenty of talk about ICD-10 has focused on the number of codes it contains. Coders will go from 17,849 ICD-9-CM codes to 69,823 ICD-10-CM codes. While the numbers may sound frightening at first glance, the change isn't really that scary, says Sue Bowman, RHIA, CCS, senior director of coding policy and compliance for AHIMA in Chicago.
In fact, Bowman says she is not sure how the idea of "too many codes" took hold in the first place. Think of the code book like a phone book. The Chicago phone book includes considerably more phone numbers than the phone book for Williamsburg, Virginia, but you'd still look up a number the same way in both of them. Similarly, ICD-10-CM contains considerably more codes, but you'll still look them up the same way you did in ICD-9-CM, Bowman says. It's not harder to find the code you want just because one book contains more of them.
In fact, the increased number of codes is actually a positive thing. "The increased specificity makes it easier to know if you are at the right code," Bowman says. "If the code is too ambiguous or vague, you aren't sure."
Many ICD-9-CM codes are open to interpretation. As a result, coders may spend more time trying to choose the most accurate code because they don't have a clear-cut choice. That's particularly true when it comes to reporting inpatient procedures. One ICD-9-CM Volume 3 code can represent more than 100 very different procedures that require different levels of care. That ambiguity can leave coders confused and guessing about correct code selection. ICD-10-PCS contains 71,924 possible codes that provide detailed information about the procedure the physician performed.
ICD-10 codes are also more clinically relevant, says Donna Smith, RHIA, project manager and senior consultant with 3M Health Information Systems in Salt Lake City. "That makes it easier to select the correct code."
Consider asthma. ICD-9-CM lists asthma as intrinsic or extrinsic, which is not terminology physicians use, Smith says. ICD-10-CM classifies asthma as:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
- Other and unspecified
"That makes sense to people," Smith says. If the physician is describing the patient's condition, coders should be able to pick the correct code.
Myth 2: Coders can't report unspecified codes
It's true that ICD-10-PCS doesn't include unspecified codes, but ICD-10-CM is full of them. Codes that require laterality include options for right, left, and unspecified.
For example, ICD-10-CM includes four choices for chronic serous otitis media:
- H65.20, chronic serous otitis media, unspecified ear
- H65.21, chronic serous otitis media, right ear
- H65.22, chronic serous otitis media, left ear
- H65.23, chronic serous otitis media, bilateral
Physicians should be documenting laterality already, says Smith.
"The better you tell the story of the patient's condition, the better it will help you in the long run," Smith says. "It's not going to get you paid more, but it will help that payment move along faster. You won't get as many denials and you won't get as many requests for additional information."
That said, while physicians should be as specific as possible, in some cases they just don't know, Smith says. ICD-10-CM guideline B.18 states:
Sign/symptom and "unspecified" codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
ICD-10-CM also includes more symptom codes than ICD-9-CM, so coders have additional nonspecific choices.
Myth 3: Physicians will need to perform unnecessary tests just for code specificity
This relates to the previous myth about unspecified codes. ICD-10-CM includes additional information about infectious diseases, including causative organisms (for diseases such as botulism or salmonella) or types (such as pneumonia).
If a physician diagnoses a patient with pneumonia but doesn't know the specific type, coders should assign an unspecified code (J18.9, pneumonia, unspecified organism). Physicians don't need to order an additional test to determine whether the patient has pneumonia due to Klebsiella pneumonia, Pseudomonas, or staphylococcus.
Guideline B.18 states:
It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
Myth 4: Clinicians had no input into ICD-10 codes
Another common myth cited by the physician community is that clinicians had no input into ICD-10 codes.
ICD-10 has always been an open forum, meaning anyone can submit information or requests for codes, Smith says. "ICD-10 has been updated yearly based on clinical input."
In fact, the vast majority of ICD-10 updates come from physician groups, Bowman says. Physician groups regularly attend ICD-10 Coordination and Maintenance Committee meetings to provide input into new codes.
Myth 5: ICD-9-CM works fine
In fact, ICD-9-CM does not work fine. The National Committee on Vital and Health Statistics actually sent a letter to the Secretary of Health and Human Services recommending the U.S. move to ICD-10 more than 10 years ago.
ICD-9-CM is outdated and out of room. It does not reflect current clinical knowledge, up-to-date medical terminology, or the current practice of medicine. It also hasn't been updated since 2011.
ICD-9-CM's limited structural design lacks the flexibility to keep pace with changes in medical practice and technology, Bowman adds. "The longer ICD-9-CM is in use, the more the quality of healthcare data will decline, leading to faulty decisions based on inaccurate or imprecise data."
The lack of specificity in ICD-9-CM also results in more frustrating back and forth with insurance companies and more records requests. Physicians and office staff must spend time dealing with record requests and administrative headaches.
For example, in ICD-9-CM, physicians cannot specify laterality in many cases. If a patient comes in with a closed fracture of the proximal phalanx of the right index finger, coders would report 816.01. Suppose the same patient comes in two days later with a closed fracture of the proximal phalanx of the left ring finger. Coders would still report 816.01. Payers may see this and reject the second claim thinking it is a duplicate code or an error in billing.
In ICD-10-CM, coders would report two different codes:
- S62.610A, displaced fracture of proximal phalanx of right index finger, initial encounter
- S62.615A, displaced fracture of proximal phalanx of left ring finger
Thanks to the separate codes, the payer knows that the patient clearly suffered two distinct fractures, which should speed up the reimbursement process.
Myth 6: We can use SNOMED CT instead of ICD-10
SNOMED CT and ICD-10 are complementary systems, not interchangeable ones. Neither can serve all current and future uses for coded data required in the U.S. healthcare delivery system, says Bowman.
SNOMED CT is designed for the primary documentation of clinical care. "When implemented in software applications, SNOMED CT can be used to represent clinically relevant information consistently, reliably, and comprehensively as an integral part of producing EHRs," Bowman says.
The ICD system defines the universe of diseases, disorders, injuries, and other related health conditions. It organizes content into meaningful standardized criteria that can be stored and retrieved for epidemiological and research purposes.
"SNOMED CT and ICD are designed for different purposes, and each should be used for the purpose for which it is designed," Bowman says.
Myth 7: We can just wait for ICD-11
ICD-11 is a long way off. The World Health Organization doesn't plan to release the codes for use until 2017 (two years later than it originally planned). But even then, the codes wouldn't be immediately ready to use. They would still need to be modified for use in the U.S., which would probably take another 20 years, Smith says.
Healthcare will miss out on the improvements associated with ICD-10 coding, such as laterality, greater specificity, and more room to add codes. In fact, CMS stated that one of its reasons for setting October 1, 2015, as the new implementation date was so the healthcare industry could reap the benefits of ICD-10 without an even longer wait.
In addition, healthcare providers and coders will have a more difficult time learning ICD-11 without learning ICD-10 first. Although the ICD-11 codes aren't final yet, the system builds on concepts introduced in ICD-10.
Editor’s note: This article was originally published in the September issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.