By Angela “Annie” Boynton BS, RHIT, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I
The need to move to ICD-10 is a well-known and ongoing saga. The current standards, ICD-9-CM Volumes I, II and III, are over 30 years old and increasingly are becoming outdated.
Several factors—including old terminology, obsolete technology, limited upgradability, and a lack of accurate international data exchange—all have furthered the need for an overhaul of the clinical classification system. To support this end, the United States is implementing the diagnostic subset ICD- 10-CM (International Classification of Disease 10th Revision with Clinical Modification) concurrently with the procedural subset ICD-10-PCS (International Classification of Disease Procedure Code System). The federal implementation compliance deadline is Oct.1, 2013.
It is a well-established fact that the United States is one of the last economically-developed nations to undergo the transition to ICD-10. Furthermore, the United States will be implementing the most comprehensive version of ICD-10; many countries (Germany, Canada, Australia, and New Zealand) implemented customized versions of ICD-10. By the time the Oct. 1, 2013 implementation mandate arrives, almost 20 years will have passed since the first of our international neighbors underwent their ICD-10 transition process.
Renal specialty coding is just one of many specialty areas that will be affected by the transition to ICD- 10. Factors to remember when implementing ICD-10 include a greater granularity/specificity, improved physician medical documentation, and a greater degree of understanding in the areas of anatomy, physiology, pathology and procedures by medical coders. Each of the preceding will affect how claims are submitted, and how they are paid, denied, appealed, and audited.
With the migration to ICD-10 it is anticipated that physicians and coders will have to work together more closely than ever before. ICD-10 brings a greater degree of clinical knowledge required by medical coders to accurately select appropriate codes. Gone are the days of repeatedly falling back on an unspecified code when a coder is not able to determine a definitive diagnosis based on documentation available. Therefore, as a natural effect, physicians will be required to document their findings better.
Many physicians are angered by the increased documentation needs, but it is important to remember that the rules for documentation are not changing with ICD-10. Ask any physician/coder team who have been audited, and they will tell you that the documentation guidelines in ICD-9 are very specific; yet the codes do not keep up with the documentation requirements because they may not be specific enough. With ICD- 10, for the first time we will have a clinical classification system that is sophisticated enough, and specific enough, to keep up with the regulations.
The ICD-10-CM, the diagnostic subset, does have some additions and changes, the most startling of which is the look of the code. Codes will have up to seven alphanumeric characters—quite different for the current five- character system we use today. Physicians should expect the learning curve for ICD-10-CM to be much smoother than the procedural counterpart. The rules, conventions, and guidelines in ICD-10 are very similar to what is currently in ICD-9, with only a few changes.
Let’s use chronic kidney disease (CKD) as an example. Currently, coders are required to make their code selection based on severity. This does not change in ICD-10. Classification of CKD in ICD-10 continues to be based on severity represented by stages I-V and is assigned from the N18 section. End-stage renal disease (ESRD) is still only assigned when it is documented, and also is assigned from the N18 section. For cases where patients have CKD with other disease like diabetes mellitus or hypertension, the ICD-10 book still directs the coder in the proper sequencing of the codes. Furthermore, there are still codes to represent the complications of transplants, but in this area there is greater specificity available to represent complications adequately. A newer concept in ICD-10-CM is the multitude of combination codes available. In ICD-9- CM what took us two or three codes may now only take one combination code in ICD-10-CM.
Take a look at this example: A patient diagnosed with malignant hypertension and stage V chronic renal disease is admitted to the critical care unit. The patient is now in acute renal failure with acute cortical necrosis.
- First listed diagnosis: I12.0 Hypertensive chronic kidney disease with stage V chronic kidney disease or end-stage renal disease
- Second listed diagnosis: N18.5 Chronic kidney disease, stage V
The procedural subset, ICD-10-PCS, is unlike anything we have seen before. It vastly differs from what we currently use as it is a seven-character, alphanumeric code that is table based. The ICD-10-PCS subset will be used highly in the inpatient facility coding arena, but knowledge of the codes at the practices level would be necessary for revenue analysis. The key to building an ICD-10-PCS procedure code is finding the correct table. This will require coders have a higher level an anatomical and pathophysiological education; a medical terminology class is no longer enough. Coders will need college-level anatomy and physiology that can help them maneuver ICD-10-PCS.
Coders will need to understand body systems, root operations, body parts, approach, and devices. Root operations could pose serious issues for coders who do not have thorough understanding of anatomy, and how procedures are performed. For example, coders will be required to differentiate between the following: excision vs. resection; inspection; occlusions vs. restrictions; release vs. division; transplantation vs. administration, etc. Practices can be on the look out for reputable anatomy classes specific for ICD-10. Many organizations are conducting or will begin conducting these classes soon. Furthermore, specialty physicians should look to their specialty societies for guidance. Many specialty societies are developing materials to help smaller practices navigate ICD-10 implementation. The bottomline is that physicians should be engaging any available resource to them, whether it is from a specialty society or even from a payer. Most payers are further down the implementation pathway and have valuable knowledge and resources to share.
The impact across various specialties, including urinary and renal specialties, is undeniable. The most profound area of impact for physicians will be on documentation. It is critically important that physicians understand the depth of information required to select diagnostic codes accurately in the ICD-10 code system. For certified coders, the increased level of anatomical knowledge that will be needed likely will present a challenge. Thus training must become a higher priority in the average medical practice. Practices will be faced with significant costs as a result; this is why it is important to begin implementation plans quickly. It will be difficult to know how extensive the costs, if practices haven’t taken the time to talk about ICD-10. Practices are facing so many other issues like Medicare/Medicaid cuts, ARRA, HITECH, and health care reform looming on the horizon, the need for practices to begin ICD-10 implementation is greater than ever.
Simply put, if practices are not compliant by the Oct.1, 2013 deadline they are risking their business. This is not an over-dramatization, it is reality. Ignoring ICD- 10 will not make it go away, and there are absolutely no signs coming out of Washington D.C. that point toward ICD-10 being delayed. On the contrary, documentation coming out of the Centers for Medicare and Medicaid Services (CMS) states that Oct. 1, 2013 is the final deadline. Therefore the only sure way that specialists can protect themselves is to begin ICD-10 implementation before it is too late. RBT
Annie Boynton is a multi-certified coder and the Director 5010/ICD-10 Communication, Adoption and Training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College and is a developer and member of the AAPC’s ICD-10 Training team. Annie frequently speaks and writes about coding matters, including ICD-10 and 5010 implementation.
