ICD-10: The Good, The Bad, and How to Prepare

ICD-10: The Good, The Bad,
and How to Prepare
Donald E. Horton, Jr.
Vice President, Public Policy & Advocacy
LabCorp
September 25, 2007
Overview
• Current Legislative and Regulatory Landscape
• The Good: Perceived Benefits of Transition to ICD-10
– Comparing ICD-10 to ICD-9
– New Features in ICD-10-CM
• The Bad: ICD-10 Implementation Challenges
– Case Study: Clinical Labs
– Examples of ICD-10-CM Complexity
• How to Prepare: Practical Steps to Get Ready
2
Legislative / Regulatory Landscape
• Pending Legislation
– US Senate Bill 628
• Introduced 2/15/07
• Currently in Senate Health,
Education, Labor and Pensions
(HELP) Committee
• Would require HHS to issue a final rule by 10/1/08 requiring:
– Implementation of ICD-10 by 10/1/11 and
– Version 5010 of HIPAA transactions by 4/1/11
• Passage this session is unlikely; the Senate HELP Committee
passed the Wired for Healthcare Quality Act without ICD-10
3
Legislative / Regulatory Landscape
• Potential Legislation
– Sources indicate House Republicans intend to introduce an HIT
bill in September that would require:
• Upgrading to version 5010 of the X12 HIPAA Transactions by April
2009
• Conversion to ICD-10 by October 2010
– House Democrats also likely to introduce HIT legislation in
September
• Likely to focus on privacy; unclear whether ICD-10 will be included
• Pending Regulation
– HHS Proposed Rule
• Sources indicate a proposed rule is under HHS review that would
require ICD-10 implementation by 10/1/11
• Questions and budget issues are slowing its release
4
Legislative / Regulatory Landscape
• Proponents of quick adoption of ICD-10 include:
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Advanced Medical Technology Association (AdvaMed)
American Health Information Management Assoc. (AHIMA)
American Hospital Association (AHA)
American Medical Informatics Association (AMIA)
Federation of American Hospitals (FAH)
Medical Device Manufacturers Association (MDMA)
Premier
Siemens
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Legislative / Regulatory Landscape
• Opponents of quick adoption of ICD-10 include:
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American Clinical Laboratory Association (ACLA)
American Medical Association (AMA)
Blue Cross Blue Shield Association (BCBSA)
College of American Pathologists (CAP)
Medical Group Management Association (MGMA)
American Association of Community Colleges
Higher Education Allied Health Leaders (HEAL Coalition)
American College of Emergency Physicians
American Society of Anesthesiologists
American Association of Orthopaedic Surgeons
American College of Gastroenterology
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The Good: Perceived Benefits of ICD-10
• ICD-9-CM (International Classification of Diseases, Ninth
Revision, Clinical Modification) has its problems...
– Developed by World Health Organization (WHO) in 1970’s,
implemented in 1979
• Diagnosis codes (used by all providers)
• Procedure Codes (used by hospitals for inpatient reporting)
– No longer supported by WHO - other industrialized nations have
adopted ICD-10
– No longer reflects modern clinical practice and current medical
knowledge
– Running out of space for new codes
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The Good: Perceived Benefits of ICD-10
• ICD-9-CM’s problems have consequences:
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Inability to collect accurate data on new technology
Increased submission of documentation to support claims
Lack of specific quality data to support health outcomes
Less accurate reimbursement for some providers
• On the procedure code side:
– Several distinct procedures performed in different parts of the
body that have very different resource utilization are grouped
under the same procedure code
• On the diagnosis code side:
– Pathologically different diseases may be grouped under the
same diagnosis code; hard to study different treatment outcomes
8
The Good: Perceived Benefits of ICD-10
• Healthcare data needs have evolved since ICD-9
– Greater demand for more specific data
– Greater focus on data to analyze quality, safety and efficacy of
medical care
– Public health and bioterrorism surveillance require more
international cooperation
– Increased importance of interoperable coded data that can be
mapped to other codes/vocabularies/terminologies in health
information exchange
– New technologies and therapies need appropriate representation
9
The Good: Perceived Benefits of ICD-10
• ICD-10 as a solution to ICD-9 problems
– ICD-10-CM (International Classification of Diseases, Tenth
Revision, Clinical Modification): Diagnosis Codes
– ICD-10-PCS (International Classification of Diseases, Tenth
Revision, Procedure Classification System): Procedure Codes
(replaces volume of 3 of ICD-9-CM for hospital inpatient
procedures)
– Restructured Classification (not just an “update” of ICD-9)
– More alphanumeric codes
– Expanded code length and narrative description
– More granularity in many areas
– New procedures and technologies are easily incorporated
10
Comparing ICD-10 to ICD-9
Code Set
Number of Codes
Characters
ICD-9-CM (Diagnosis)
13,000
Up to 5, alphanumeric
plus decimal
ICD-10-CM
(Diagnosis)
120,000
Up to 7, alphanumeric,
case sensitive, plus
decimal
3 or 4 numeric digits,
decimal after second
digit
7 alphanumeric
characters, no decimal
ICD-9-CM (Procedure)
4,000
ICD-10-PCS
(Procedure)
86,617
11
Comparing ICD-10 to ICD-9
•
ICD-10 Major Changes:
– Expansion of Detail (2,033 categories - 855 more than ICD-9)
– Injuries restructured:
• ICD-9, Type of Injury
– Fractures 800-829
– Dislocations 830-839
– Sprains/Strains 840-848
•
ICD-10, Site of Injury
-- Injuries to Head S00-S09
-- Injuries to Neck S10-S19
-- Injuries to Thorax S20-S29
ICD-10-CM Major Changes
– Added trimesters to OB codes (fifth-digits from ICD-9-CM will not be
used)
– Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be
used)
– Expanded codes (e.g., injury, diabetes, postoperative complications,
alcohol/substance abuse)
– Added code extensions for injuries and external causes of injuries
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Diabetes: From ICD-9-CM to ICD-10-CM
ICD-9-CM
ICD-10
ICD-10-CM
250.X
E10.X Insulindependent
E11.X Non-insulin
dependent
E12 Malnutritionrelated
E13 Other specified
E14 Unspecified
4th digit for type of
complication
E08 Diabetes due to
underlying condition
E09 Drug or chemical
induced diabetes
E10 Type 1 diabetes
E11 Type 2 diabetes
E13 Other specified
diabetes mellitus
E14 Unspecified
4th digit identifies type
of complication
5/6th digit for type of
complication
4th digit identities
type of
complication
5th digit “1”
identified juvenileonset
5th digit “0”
identified adultonset
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New Features in ICD-10-CM
•
Injury & External Cause Chapter Extensions in ICD-10-CM
– a Initial encounter
– d Subsequent encounter
– q Sequelae
•
Fracture Extensions in ICD-10-CM
– a Initial encounter for closed fracture
– b Initial encounter for open fracture
– d Subsequent encounter for fracture with routine healing
– g Subsequent encounter for fracture with delayed healing
– j Subsequent encounter for fracture with nonunion
– q Sequelae
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New Features in ICD-10-CM
•
Place of occurrence
– Y92.0x Home
– Y92.1x Residential institution
– Y92.2x School, other institution and public administrative
area
– Y92.3x Sports and athletic area
– Y92.4
Street and highway
– Y92.5x Trade and service areas
– Y92.6
Industrial and construction area
– Y92.7
Farm
– Y92.8x Other specified place
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New Features in ICD-10-CM
•
Activity
– Y93.0x Injured while engaged in sports activity
– Y93.1
Injured while engaged in leisure activity
– Y93.3x Injured while engaged in other types of work
– Y93.4
Injured while resting, sleeping, eating or
engaging in other vital activities
– Y93.8
Injured while engaged in personal hygiene
– Y93.9
Injured during unspecified activity
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The Bad: ICD-10 Implementation
Challenges
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Cost
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Development Issues
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Conversion Issues
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Training Issues
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Cash Flow and Productivity Issues
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Coordination with Other Activities
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The Bad: ICD-10 Implementation
Challenges
•
•
Cost: Hold on to your wallet...
System Changes:
– Rand $700 Million
– Nolan: $10.6 Billion
•
Training:
– Rand: $400 Million
– Nolan: $1.5 Billion
•
Productivity:
– Rand: $450 Million
– Nolan: $1 Billion
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Recontracting:
– Rand: n/a
– Nolan: $400 Million
GRAND TOTALS:
RAND: $1.55 BILLION
NOLAN: $13.5 BILLION
COMPARE
HIPAA TCS EXPERIENCE:
HHS Impact Analysis:
$1 Million Per Payer
Actual: $21 Million Per Payer
(from survey of small to mid-size
plans, ranging from $6-34 Million)
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The Bad: ICD-10 Implementation
Challenges
•
Development Issues: Anything that includes ICD-9 codes will
require changes
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Programs
Screens
Reports
Requisitions
Forms (printed or electronic)
Interfaces
Contracts
Policy manuals
[INSERT ADDITIONAL
ITEMS HERE....]
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The Bad: ICD-10 Implementation
Challenges
•
Development Issues: Impact of New Code Descriptions on Storage,
Screens and Forms Design
– ICD-10 code descriptions are much more descriptive; longer
abbreviations necessary for understanding
• ICD-9 descriptions:
– Short, 24 characters
– Long, 255 characters
• ICD-10 descriptions:
– Short, 24 characters
– Medium, 70 characters
– Long, 255 characters
– Storage of longer descriptions requires increased storage and file and
database changes
– Screens, displays, forms and reports must accommodate drop down
menus with new descriptions, more landscape for larger data fields
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The Bad: ICD-10 Implementation
Challenges
•
Development Issues: The current version of HIPAA standard
transactions, ASC X12 N 4010A1, does not support ICD-10
– ASC X12 N 5010 does support ICD-10, but:
• 5010 contains approximately 845 changes from 4010
• Will require two years (from Final Rule) to analyze, program, test, implement
and evaluate
– Implementation of 5010 is a pre-requisite to implementation of ICD-10
– ICD-10 cannot be implemented simultaneously with 5010
– Transactions that must upgrade to 5010 to support ICD-10:
• 837 (claims, encounters, and coordination of benefits)
• 278 (referral certification and authorization)
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The Bad: ICD-10 Implementation
Challenges
•
Conversion Issue: Support of multiple code sets
– Dual usage of ICD-9 and ICD-10 will be needed for some period of time
to accommodate different implementation schedules among trading
partners
•
Conversion Issue: Crosswalk Mapping
– Backward Mapping ICD-10-CM to ICD-9-CM: “Many to One” mapping;
official rules will be available, will be used for several years
– Forward Mapping ICD-9-CM to ICD-10-CM: “One to Many” mapping;
official rules may be available, but user intervention may be needed;
may be used for several years
– SNOMED-CT Crosswalks
• May need maps between SNOMED-CT and ICD-10-CM
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The Bad: ICD-10 Implementation
Challenges
•
Other Conversion Issues
– Longitudinal studies requiring common nomenclature
– Clinical Decision Support Systems
– Disease Management and Case Management
– Data Warehousing
– Tumor registries and other repositories
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Case Study: Clinical Labs
• As indirect providers, clinical labs generally do not
have patient contact, as specimens are often
collected in the physician’s or other provider’s office
• Currently, clinical labs are required to submit
diagnosis codes in all electronic claims and in most
paper claims to third party payers
• Clinical labs are generally dependent upon ordering
providers to provide diagnosis codes
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Case Study: Clinical Labs
• Many clinical labs experience significant front-end claim
suspensions due to missing ICD-9-CM coding, requiring
follow up
• Without adequate physician office training on ICD-10CM, lab claim suspension could increase significantly,
requiring more follow up and impacting cash flow
• Physician office training will be critical to labs
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Case Study: Clinical Labs
• Many clinical labs employ certified translators to
translate narrative diagnoses to the appropriate ICD-9CM code
• Current translator qualifications include various
comprehensive training and certification programs
• Due to the complexity of ICD-10-CM, more highly
qualified (more expensive) specialists may be needed
for translation; narrative diagnoses may no longer be
acceptable
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The Bad: ICD-10 Implementation
Challenges
• Significant effort will be required to transform information
systems for ICD-10-CM; HIPAA TCS was easy by
comparison
• Business rule development, programming, testing, and
implementation must occur for hundreds of internal
software programs
• Hundreds of external interfaces must be remapped
• End-to-End Testing with Trading Partners will be
necessary to verify that the changes are working - but
few such opportunities existed during HIPAA TCS
conversions
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The Bad: ICD-10 Implementation
Challenges
• Coordination of Benefits (COB) may become very
difficult due to differing interpretations of ICD-10-CM
• ICD-10-CM’s alphanumeric, case sensitive structure
could result in confusion of “O” with “0” and “I” with “1”,
or vice versa
• Transition to ICD-10-CM could slow transition to
standard electronic transactions not yet fully utilized
(e.g., the 835 electronic remittance, and the 270/271
eligibility inquiry and response)
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The Bad: ICD-10 Implementation
Challenges
• ICD-10-CM’s seven (7) - character code length,
alphanumeric structure, and 120,000 codes will require
more storage capacity and more complex programming
than required by ICD-9-CM’s five (5) - character code
length, numeric structure, and 13,000 codes
• Dual usage of ICD-10-CM and ICD-9-CM will place a
strain on system resources
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The Bad: ICD-10 Implementation
Challenges
• Implementation of ICD-10-CM may slow implementation
of health information exchange initiatives (e.g., RHIOs,
adoption of EHRs)
• Coverage decisions by third party payers based on
medical necessity will change to reflect ICD-10-CM
• Simultaneous implementation of ICD-10-CM, Claim
Attachments, National Health Plan Identifier (NHPI),
transaction version updates and other initiatives would
be burdensome and costly
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Examples of ICD-10-CM Complexity
• Confusion of “O” with “0”:
– O00.1 Tubal Pregnancy
– S82.121o Displaced fracture of lateral condyle of right tibia,
subsequent encounter for open fracture type III, IIIB or IIIC with
malunion
• Confusion of “I” with “1”:
– I11.0 Hypertensive heart disease with heart failure
– S82.121l Displaced fracture of lateral condyle of right tibia,
subsequent encounter for open fracture type IIIA, IIIB or IIIC with
nonunion
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Examples of ICD-10-CM Complexity
• “x” Placeholders
– T37.8x4a Poisoning by other specified anti-infectives and antiparasitics, undetermined, initial encounter
– T37.94xa Poisoning by unspecified anti-infective and
antiparasitics, undetermined, initial encounter
• Down Syndrome - Granularity and Description Length
– ICD-9-CM: 758.1 Down Syndrome
– ICD-10-CM:
•
•
•
•
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Q90 Down Syndrome
Q90.0 Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1 Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2 Trisomy 21, translocation
Q90.9 Down syndrome, unspecified
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How to Prepare
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How To Prepare
• Form an ICD-10-CM / ICD-10-PCS Transition Team
– Information Systems
– Billing
– Operations
– Legal
– Compliance
– Internal Audit
– Coders / Translators
– Communications / PR / Marketing
• Educate and gain support of senior management
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How to Prepare
• Educate yourself on ICD-10-CM at www.cdc.gov/nchs
• Educate yourself on ICD-10-PCS at www.cms.hhs.gov
• Closely monitor ongoing policy developments relating to
compliance dates for 5010 and ICD-10
• Comment on proposed rules to identify issues and
propose solutions
• Once definite compliance dates are mandated, develop
a timeline for conversion to 5010 and ICD-10
– Consult advisory group recommendations (e.g., NCHICA,
NCVHS, WEDI)
– Consult with payers and payer organizations (e.g., BCBSA)
– Consult with other providers and provider trade organizations
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How To Prepare
• The timeline should:
– Recognize the necessity of implementing the 5010 version of
standard transactions before implementing ICD-10-CM
– Seek to coordinate efforts with payers and ordering providers
– Incorporate phases for analysis, development, internal testing,
external trading partner testing and implementation for both 5010
and ICD-10-CM
– Emphasize the importance of appropriately timed education,
internally and externally
• Address budgeting and staffing issues
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