Anyone trying to plan for a transition to ICD-10-CM (the United States' Clinical Modification of International Classification of Diseases, 10th Revision) must sometimes feel like Annie of the Broadway hit: "Tomorrow, tomorrow... You're always a day away!" Many standards-watchers expect the U.S. Department of Health and Human Services (HHS) to soon announce its intent to replace ICD-9, the present U.S. mortality and morbidity coding standard, with ICD-10, a far more precise system. But many also admit to having expected this notice before--even as early as 1996, when passage of the Health Insurance Portability and Accountability Act (HIPAA) pushed ICD-10 to a lower position on the HHS priority list.
Today, a spokesperson for HHS's Center for Medicare & Medicaid Services (CMS) says only that the agency continues to study the costs and benefits of a proposed rule. The expert consensus, however, is that healthcare IT leaders should be getting ready for ICD-10. "It's not a question of if," says John Quinn, Health & Life Sciences, Accenture, New York, who also chairs the American National Standards Institute's HL7 technical steering committee, "it's a question of when. This has been in development since the 1990s. It's not something that was developed last night on the back of a napkin."
"It's coming," agrees Washington, D.C.-based Richard Gundling, vice president of the Healthcare Financial Management Association (HFMA). "I don't have a good estimate of the date, but sooner rather than later."
What 10 has that 9 doesn't
Developed by the World Health Organization (WHO), the United Nation's public health arm, ICD-9 has been the U.S. standard for reporting on patient diagnosis and inpatient procedures since 1979. It's used both for studying clinical issues and for coding reimbursement claims to insurers. ICD-9 uses three to five alphanumeric characters to generate codes for classifying diagnoses and three or four numeric characters for medical procedures. That's not enough digits for the evolving understanding of disease and the multitude of new procedures developed during the past three decades.
"We've outgrown the coding system," Quinn says. "There isn't enough room to code all the detail that medical science has come up with. And the rest of the world has gone ahead of us."
ICD-10 is based on a classification logic that differs significantly from ICD-9. It utilizes up to seven alphanumeric characters with the mathematical potential to generate billions of codes. Currently, its diagnostic classification set (ICD-10-CM) includes about 120,000 codes, almost 10 times the number now used under ICD-9. And its procedure usage set (ICD-10-PCS) includes more than 200,000 codes, roughly 50 times as many as ICD-9.
The WHO first released ICD-10 in 1993. The National Committee on Vital and Health Statistics (NCVHS), the National Center for Health Statistics of the Centers for Disease Control and Prevention, and CMS (then HCFA) promptly contracted with 3M Health Information Systems, Salt Lake City, to develop detailed plans for migration to ICD-10. In 1999, the United States adopted ICD-10 for reporting deaths. However, the United States is still using ICD-9 for coding morbidity statistics, the only industrialized country to do so.
Support for the switch
The most aggressive advocate for a switch to ICD-10 is the American Health Information Management Association (AHIMA), Chicago. Linda Kloss, its executive director, says, "When you look across healthcare, it's remarkable how much we rely on coded data. It's ubiquitous. It frames our statistics. It drives reimbursements. It's a key component in research and drug trials. And the quality of the data simply isn't what it could be and should be."
Several professional organizations support a shift to ICD-10, including the Chicago-based HFMA, American Medical Association and American Hospital Association. In late July, testifying for AHIMA before a Congressional subcommittee, Kloss urged Congress to prod HHS to act on ICD-10 by early in 2006. She stated that the greater specificity of ICD-10 is needed to:
- Support initiatives to enhance healthcare quality and promote patient safety, including disease management and pay for performance
- Improve monitoring of public health issues, including bioterrorism threats
- Provide the basis for more accurate reimbursement rates
"I think one of the big benefits," says Nancy A. Larson, vice president of 3M Health Information, "is being able to drive fairer payments because you have more specificity in coding. The system can capture procedures involving medical device innovations that can't be accommodated in ICD-9, permitting more accurate reimbursement."
For one of the nation's largest healthcare organizations, the Veterans Health Administration (VHA), Washington, D.C., a shift to ICD-10 can't come soon enough. Director of Health Data and Informatics Gail Graham points out that the VHA is both a provider and a payer, one that pays out more than $2 billion per year and accepts outside claims electronically.
"We use these codes for a lot of other purposes than billing," Graham says. "We use them to evaluate clinical interventions. We have an electronic health record, and ICD-10 gives you the granularity to make clinical reminders a little more sophisticated than they are today. Some of the ICD-9 codes lump several different diagnoses in one bucket. We try to tailor reminders to the patients as much as we can, and we really hope that ICD-10 will help us refine that."