Published in the December 2011 issue of Today’s Hospitalist
WE ALL RECOGNIZE that there are major problems with the medical school curriculum. It devotes hours to esoteric stuff of little practical importance, but doesn’t pay nearly enough attention to the hundreds of daily issues that crowd our professional lives. With an education like that, it’s a small miracle that any of us is practicing medicine competently.
If we ran a medical school, we’d forget the forest and the trees, and start instead with some very “big picture” lectures, the equivalent of satellite images of the earth below. One of the first lectures would be on the International Classification of Diseases (ICD).
A little history
The ICD was first issued in 1893 as the “International List of Causes of Death.” The document, which focused mainly on mortality, was updated roughly every 10 years beginning in 1900.
What’s the difference between ICD-9 and ICD-10? Think paper maps vs. GPS.
Various countries, including the U.S., introduced parallel classification systems of injuries and nonfatal illnesses. The morbidity and mortality rubrics were merged into one “Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death,” published in 1949.
Subsequent revisions occurred in the 1950s, 1960s and 1970s. The ninth iteration, known as ICD-9, should start to ring a few bells. Think numbers “lots of numbers “and your friendly neighborhood coder.
A tenth revision, ICD-10, entered general use in 1994, but the U.S. has been very slow on the uptake. So slow, in fact, that ICD-11 has already appeared in draft form before ICD-10 has been implemented here, an embarrassing 20-year lag. But the clock is ticking: Electronic claims will need to conform to ICD-10 starting next month, and physicians will need to use ICD-10 diagnostic codes beginning October 2013.
Numbers and letters
As you all know, ICD-9 is organized into 19 chapters, many of them dealing with diseases of a specific organ. ICD-9 offers some 14,000 codes to choose from.
ICD-10 retains a similar organization. But the number of diagnostic codes balloons to 68,000. (Plus, there are an additional 87,000 procedure codes, an astonishing increase from the mere 4,000 in ICD-9.)
What’s the difference between the two systems? Think paper maps vs. GPS. In both ICD-9 and ICD-10, each code starts with a three-character category. (See “Gross anatomy of ICD-9 and ICD-10 codes.”) In the former, the first character can be either a number or letter; in the latter, the first character is always a letter. Remaining characters further qualify the diagnosis with respect to etiology, location and severity. ICD-9 codes have up to five characters in total, while ICD-10s can tack on another two.
A presentation posted on the CMS’ Web site provides some good examples of how ICD-10 will affect hospitalists. In ICD-9, for example, acute coronary syndrome is reduced to four digits (411.1). ICD-10, on the other hand, requires much greater specificity. One option (among many) is “arteriosclerotic heart disease of native coronary artery with unstable angina pectoris,” which becomes six characters (I25.110).
Another example is a fracture of the clavicular shaft. ICD-9 summarizes this in five digits (810.02) without further specificity. ICD-10 stretches this to seven characters (S42.022A) that add much more texture: “displaced fracture of shaft of left clavicle, initial encounter for closed fracture.”
The changes are so far-reaching that the World Health Organization (WHO), in addressing frequently asked questions about ICD-10, states simply: “It is not possible to convert ICD-9 data sets into ICD-10 data sets or vice versa.”
Implications and suggestions
The spiritual teacher Eckhart Tolle provides some sage advice about new wrinkles in life: “Remove yourself from the situation, change it, or accept it totally.”
In terms of ICD-10, option 1 is self-defeating; you’d need to leave medicine. Option 2 is futile because there is no way to deflect or stop the incredible momentum for ICD-10 at the CMS (and elsewhere). Option 3 is the only sane choice, which means getting on board sooner rather than later. (Notice that whining, protesting and ignoring weren’t on the menu, probably because they don’t lead to anything good.)
It’s estimated that physicians will need about five hours of training to get up to speed on ICD-10. But we’ve been admonishing readers for years to make their medical documentation very specific. Some of this granularity disappears in ICD-9 but will yield dividends following the transition to ICD-10. If you haven’t already started, begin beefing up your diagnoses. Some easy options are to include proximate causes and severity. (See “What details count in ICD-10?“) So instead of simply charting “hypokalemia,” try adding a few bells and whistles and go instead with “hypokalemia due to diuretic therapy, moderate,” for example. And why settle for just “heart failure” when you could specify systolic or diastolic and add the stage or grade?
While we’ll be writing more about all this in the coming years, consider becoming a serious student of ICD in the meantime. You can play with ICD-10 on the CMS Web site. You can also snag ICD-9 and ICD-10 iPhone apps for a couple bucks. Your coders will be astonished and ecstatic if you start using the ICD-9 app now. Moreover, you will be much better prepared for ICD10 when it’s time to throw the switch.
David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. He serves as system medical director for addiction medicine and can be reached at firstname.lastname@example.org. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.
The ICD-10 revIsIon includes four times as many codes as the version that physicians are now using. That means that codes are about to become much more specific.
How so? Here are some issues you’ll need to consider (and document) to help coders pick the right ICD-10 code:
- stage or grade of disease;
- unilateral or bilateral condition;
- acute or chronic;
- severity: mild, moderate, severe;
- specific anatomical location such as specific extremity, cranial nerve, part of the colon;
- controlled or uncontrolled;
- root cause (is the DVT due to subtherapeutic INR or medication noncompliance?); and
- episode of care: initial vs. subsequent.