The Patient Protection and Affordable Care Act of 2010 (PPACA) mandates that the healthcare industry change the way it reports medically necessary services for reimbursement. ICD-9-CM, which has been the standard for reporting healthcare transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), be replaced by ICD-10 in October, 2013.
The International Classification of Diseases (ICD) is a set of codes designed by the World Health Organization. Each country adapts it to its own uses to describe medical conditions, and medical services. While the United States has been using The international Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), the rest of the industrialized world has been using ICD-10.
ICD-9-CM codes have been used as the standard for communicating medical conditions, and for reporting medical procedures in the inpatient setting, since the 1980s. As medical science has progressed, many professionals have complained that the current system has outlived its usefulness. The rest of the world uses ICD-10, which was created by the World Health Organization to address these concerns. The U.S. has been slow to adapt ICD-10 because of the administrative costs associated with a complete transition to a new coding system. Software systems will need to be updated, and the people who assign medical codes will need to be trained in the new methodology.
Why ICD-9 Needs to be Replaced
While medical coding relies on specificity to communicate information, ICD-9-CM does not allow for the full range of diagnoses that are used today. Many diseases fall under the “Not Elsewhere Classified” codes that end with a fifth digit of 8. The ICD-9-CM code sets, as currently constructed, have been filled. ICD-10-CM allows for greater specificity, such as whether a burn is on the right arm or the left arm. Characters in the ICD-10-CM codes will identify specifically where the burn is located.
With certain ICD-9-CM chapters already full of available codes, ICD-10-CM expands the options and lets codes fall in a logical order. Prior to ICD-10, new codes were assigned according to availability in the code manual, meaning that related conditions were found out out of sequence. With ICD-10-CM, the logic of the coding system is restored, and codes are more easily identified and recognized.
ICD-10 includes advances in medical science and practice that have occurred since ICD-9 was adopted by the United States. While many professional medical billers and certified medical coders have spent their careers with the current situation, many chaff at having to use unspecified or not-elsewhere-classified codes to describe medical conditions and procedures. People who analyze medical statistics and third-party payers who use ICD-9-CM to determine whether medical claims meet coverage obligations, have long complained that a more accurate system is needed to accurately describe a patient’s encounter with the healthcare system.
ICD-9 Versus ICD-10
According to the American Medical Association (AMA) ICD-9-CM contains approximately 13,000 codes. ICD-10, both the clinical modification (ICD-10-CM) for diagnosis coding, and the procedural coding system (ICD-10-PCS) will contain 68,000 available codes. Many of these additional codes fall within ICD-10-PCS, which will replace Volume 3 of ICD-9-CM, but the diagnosis coding methodology will also be affected.
ICD-9-CM codes are between three and five characters in length. ICD-10-CM code are between three and seven characters. Most ICD-9 codes are composed of numbers only, except codes that start with E, which are used to describe causes of injury, and codes that start with V, which are used to describe conditions that are not diseases or symptoms that lead to medical encounters. In ICD-10, all codes will start with a letter, to identify where in the coding system a described condition or procedure falls within the overall coding methodology.
The ICD-9 coding system has little room for new codes. ICD-10 offers more room to add new codes within the established framework. ICD-9 contains many vague codes, while ICD-10 allows for more specific codes. Granularity of reported data is an important concern when tracking the utilization and effectiveness of medical services. It is expected that the implementation of ICD-10 will allow for more transparency, and for more accurate reporting of procedures, diseases, and symptoms, than has been possible before. Finally, ICD-9 does not capture the laterality of a condition or procedure. ICD-10 contains digits appended to codes to convey whether a condition happened on the right side or the left side. This creates transparency, so that third-party payers and statisticians can recognize a new injury from a pre-existing condition.
Making the Transition
Professional medical billers and certified medical coders are fluent in the language of medical code. When a medical coder reads the words, “mixed hyperlipidemia,” he or she reads it as 272.2 in ICD-9-CM code. In ICD-10-CM, it will be E78.2. Medical billers and medical coders who are trained in, and who are comfortable with, ICD-9-CM will be able to make the transition to a new code set relatively easily.
The Centers for Medicare and Medicaid Services (CMS) which administrates the use of medical coding for reimbursement purposes under HIPAA, is agency under the federal Department of Health and Human Services (DHH). DHH set the implementation date for ICD-10 as October 1, 2013. Many professional coding organizations, such as the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA), recognize that professional coders and billers will be able to adapt easily to this change. The key is in their training and in their professional practice.
Professional medical billers and certified medical coders have usually completed a formal program of study from a university, a community college, or a private educational institution. Their training is grounded in the philosophy and methodology of medical coding makes them adaptable changes in the industry.
The AAPC and AHIMA both recommend training in ICD-10 close to the implementation date of October 1, 2013. Both bodies recognize that training received too early will be forgotten if it is not used on a regular basis. Both bodies recommend that professional medical billers and certified medical coders should receive formal training no sooner than three months before the mandated implementation date.
Both bodies also recognize that experienced medical billers and coders, who use medical code every day, should be able to make the transition fairly seemlessly. Already cognizant of all the issues involved when assigning medical codes accurately, based on documentation, professional medical billers and medical coders should be able to recognize the logic of ICD-10-CM and ICD-10-PCS, and be able to pick up the new methodology after minimal orientation. The AAPC states that a minimum of three days of training be provided to medical coders and billers in anticipation of the transition, while acknowledging that some coders and billers may need only one session of basic orientation.
ICD-10 has been the industry standard for medical coders who code morbidity and mortality statistics for the federal Center for Disease Control and Prevention (CDC). Certified Tumor Registrars (CRTs) are also conversant with the conventions of ICD-10-PCS. Based on the experience of these coding specialists, many professional coding organizations anticipate little loss in work flow when the final transition to ICD-10 takes place.
Professional medical billers and certified medical coders use their training to adapt to changing regulatory circumstances every day. Whether they are employed by healthcare providers in private practice, by hospitals, by rehabilitation facilities, or by ambulance companies, or durable medical equipment supplies, they all understand the importance of assigning the correct code in any given situation. ICD-10 will change the codes they employ, but it will not change how they approach each case. ICD-10 presents a challenge to provide more accurate information. As professionals, appropriately trained medical billers and certified medical coders will be up for the job, and they will be in demand by employers.