Healthcare Law Blog

Are U.S. Providers Ready to Catch Up in Medical Coding?

After the bungled introduction of HealthCare.gov, providers are unquestionably leery of other technical health care-related requirements on the horizon. If there is a lesson to be learned in the wake of the Health Exchange debacle, it is this: it is never too early to prepare for change.

In January 2009, the Department of Health and Human Services (“HHS”) published a regulation requiring the replacement of ICD-9 with ICD-10 codes beginning October 1, 2013. Luckily, in September 2012, HHS pushed back the compliance date to October 1, 2014. While this deadline is months away, if you or your practice have not already taken steps to convert to ICD-10 codes, you are already behind.

Background

ICD-9-CM is a three-volume set of codes designed for the classification of information and data on patient morbidity and mortality. The World Health Organization (“WHO”) creates these codes for the purposes of standardizing diagnosis throughout the world. ICD-9 volumes 1 and 2 contain reporting codes for diagnoses and symptoms and volume 3 contains codes for reporting hospital inpatient procedures. In addition to inpatient procedure codes, the Current Procedural Terminology (“CPT”) and Healthcare Common Procedure Coding System (“HCPCS”) are used for reporting services and procedures in office and outpatient settings.

In October 2014, the ICD-10-CM will replace ICD-9-CM volumes 1 and 2 and ICD-10-PCS (“Procedure Coding System”) will replace ICD-9-CM volume 3.

ICD-10 has been only minimally used in the United States – for reporting hospital inpatient cause of death since 1999, even though the ICD-10 received the WHO’s endorsement over twenty years ago. In fact, the United States is the only industrialized nation that has not fully implemented the ICD-10 codes. In contrast, the United Kingdom adopted ICD-10 codes in 1995.  

ICD-9 codes are mostly numeric with 3-5 digits, whereas the ICD-10 codes are alphanumeric with 3-7 characters. The codes found in ICD-10 are far more descriptive and detailed than the ICD-9 codes.

Why Change Now?

The cynical answer is “Why not? Everything else is changing.” But, acknowledging that many providers are already overburdened with tedious and sometimes unnecessary changes, this coding change is for the better.

ICD-9 codes are not reflective of current medical knowledge. Moreover, ICD-9 contains outdated and obsolete terms that are inconsistent with current medical practice.

The structure of ICD-9 limits the number of new codes that can be created for a chapter. Coding chapters are divided according to body systems. Many of the complex body system chapters are now full and no new codes can be added. As a result, any additional codes for these complex systems must be added to a non-corresponding chapter, which creates a piece-meal and complicated arrangement.

This change in coding has the potential to vastly improve providers’ everyday practice. With ICD-10’s specificity and detail, providers will be better able to track patient improvement and outcomes, along with the costs associated therewith. This goes hand-in-hand with the Affordable Care Act’s emphasis on quality of patient care.

Moreover, the ICD-10 codes should enable providers to better compare their performance and outcomes with their peers. For instance, the finer detail in the codes will allow providers to give more detail about the procedures used and related outcomes. Medical complications and medical safety codes are greatly expanded in ICD-10, which can lead to improved preparedness, evaluation, and outcomes. These codes may even lead to research that changes the way procedures are performed.

The increased specificity in ICD-10 can also reduce costs. The ICD-9 codes were implemented before prospective payment systems came into existence. The vague and outdated terminology contained in ICD-9 creates confusion and makes it difficult for payers to decipher or interpret what is actually being done and what is medically necessary. As providers well know, additional documentation is almost always required to support claims for payment as a result of the vagueness of ICD-9 codes. Thus, the detail and specificity of ICD-10 codes will likely enable payers to better understand submissions and reduce the need for accompanying paperwork. Moreover, the ICD-10’s logical flow and organization will hopefully lead to less coding errors, which in turn will lead to fewer rejected reimbursement claims.

Of course, there is also the benefit of catching up to the rest of the world. The U.S. will now be able to better respond to requests for information from the WHO and track health concerns that present a global threat.

Now that you know the basics and why ICD-10 is needed, check back on Thursday for more details about how to prepare.

Services may be performed by others.

This article does not constitute legal advice.