The differences between the ICD-10 and ICD-9 code sets are primarily in the overall numbers of codes, their organization and structure, code composition, and level of detail. ICD-10-CM contains about 70,000 diagnosis codes compared to approximately 14,000 in ICD-9-CM, and approximately 72,000 in ICD-10-PCS (procedure) codes compared to 4,000 ICD-9-CM codes. ICD-10 codes are also longer and use more alphanumeric characters.
Punctuation within both the tabular and alphabetic indices still plays an important role in code interpretation and selection. When coders need to find their way around the codes, they can use either the alphabetic or tabular index. The biggest variation is that the ICD-10 tabular index uses more tables to drive digit selection. While very similar to ICD-9, CDI specialists and coders should review the ICD-10 indices to ensure accurate code selection.
Each ICD-10-CM code is three to seven characters long. The first is an alpha character, the second is numeric, and the third through seventh can be either alpha or numeric, with a decimal after the third character. Alpha characters are not case-sensitive. ICD-10-CM uses a placeholder character “X,” as the fifth character to allow for future code expansion in a particular area.
In ICD-9-CM it takes multiple codes to fully describe the patient’s clinical picture. Take, for example, diverticulitis of the large intestine with perforation or peritonitis with bleeding. Under ICD-9-CM coding conventions, there are two codes to assign, one for the diverticulitis with hemorrhage/bleeding and one for the peritonitis. Under ICD-10-CM conventions, there is a combination code to capture this clinical event, K57.41.
Pressure ulcers are another category of codes that this difference can be seen in that ICD-10-CM provides a more precise and descriptive code through combining the site and stage of the ulcer all in one code category, L89. For example, a Stage III pressure ulcer of the heel codes to L89.603.
The ICD-10-PCS codes are used for hospital claims for inpatient procedures. These codes differ from the ICD-9-CM procedure codes in that they have seven characters that can be either alpha (non-case sensitive) or numeric. The numbers 0-9 are used. Letters O and I are not used to avoid confusion with the numbers zero and one. The codes do not contain decimals.
Because ICD-10-PCS boasts more than 155,000 possible code combinations (ICD-9 only has 17,000), the increased number of codes allows ICD-10-CM/PCS to be far more specific than its predecessor. So, to report the new codes, the medical record documentation needs to reflect not only the procedure performed, but also how the physician performed it.
For example, the fifth character identifies the surgical approach for the procedure. (See Figure 2.1.) This forces the coder to consider how the procedure was performed at a level of detail previously unnecessary. And, more importantly for CDI staff, physicians previously did not necessarily need to document that level of specificity either.
Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.
Implementation costs and plans took center stage at The House Energy and Commerce Committee’s subcommittee on health’s ICD-10 Implementation hearing yesterday. Seven witnesses testified before the subcommittee about the benefits of ICD-10 implementation. Members of the committee then asked witnesses a wide range of questions. Six of the witnesses were pro-ICD-10. The lone voice against came from William Jefferson Terry, MD, a practicing urologist from Alabama who represented the American Urological Association.
Although the Congressional committee members weren’t quite 100% pro-ICD-10, most conceded that the move to ICD-10-CM/PCS was indeed needed. Rep. Kathy Castor (D-Florida) did urge no more delays and Rep. Chris Collins (R- New York) said we should get ICD-10 sooner rather than later.
Not surprisingly, the cost of the transition came up repeatedly and the projected costs varied widely. Edwin M. Burke, MD, from the Beyer Medical Group in Missouri, told the subcommittee that his small practice (two physicians and three nurse practitioners) was already using ICD-10 and they had no problems making the switch. He also said they incurred no additional costs. Their software vendor handled all of the transition work.
“We did not have special training,” Burke said. “We did not spend any money in preparation. We did not see less patients and our practice did not suffer. As providers, it was not frustrating or scary. It just was.”
Rich Averill, director of public policy for 3M Health Information Systems, brought up the just-published Professional Association of Health Care Office Management (PAHCOM) survey that put the costs of implementing ICD-10 for a small practice at approximately $8,000. He also mentioned that two other recent studies put the costs even lower.
Here’s the thing. People will procrastinate. It’s human nature. If you don’t give people a drop-dead deadline, they put it off. Everyone on the subcommittee and all of the witnesses agreed we need ICD-10. So let’s end the suspense and make October 1, 2015, THE date.
Q: Our facility is considering having our coders and CDI specialists “go–live” with ICD-10-CM/PCS on July 1, for practice to help off-set the impact of ICD-10. The system will would then code backwards into ICD-9-CM for billing. Is this “backward mapping” method appropriate?
A: The biggest issue is how your ICD-10-CM/PCS coding will be “translated” into ICD-9-CM for claims processing until CMS accepts ICD-10-CM/PCS codes to process claims. If you the system is coding backward code, the resulting code will likely be based on GEMs, which CMS discourages.
CMS specifically states the GEMS are not for coding purposes, but rather to help build coding databases. Backward mapping—going from an ICD-10-CM/PCS code to an ICD-9-CM code—could be problematic, and could result in assigning many nonspecific codes, which may have reimbursement ramifications. The GEM mappings were not intended to be used for coding purposes, but rather to help build coding databases.
Many codes have a “one to many” ratio, resulting in either a nonspecific code or, in some cases, a “no map” option. Ideally, we would like to think if we convert documentation to ICD-10-CM/PCS that it would automatically backward map to the correct ICD-9-CM code, but it may not.
For example, if the documentation states “severe persistent intrinsic asthma,” the ICD-10-CM assigned code would be to J45.50 (severe persistent asthma, uncomplicated), because the term “intrinsic” in ICD-10-CM/PCS is now an included term not previously factored into category selection in ICD-9-CM. So, if you backwards map the code J45.50, it will translate to 493.00 or 493.10 in ICD-9-CM.
Unfortunately, this does not translate to a direct match: 493.00 is for extrinsic asthma and 493.10 is for intrinsic asthma. The ICD-10-CM/PCS code translates to two possible ICD-9-CM codes, and only one can be chosen. But it has to backward map to both because the code for severe persistent asthma does not identify extrinsic or intrinsic in ICD-9-CM.
Most organizations are dual-coding–coding in both ICD-9-CM so their claims can be reimbursed appropriately and in ICD-10-CM/PCS so they can practice the new code set and identify improvement opportunities. However, not all organizations have software that can “hold” both code sets simultaneously. If your software allows you to hold both codes, even though it is time consuming, the best suggestion is to native code in both ICD-9-CM and ICD-10-CM/PCS. If you rely merely on the backwards mapping, it may not achieve the desired result. The systems are not identical, and very few codes have exact maps.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass. and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of HIM and Coding at HCPro in Danvers, Mass. contributed to this response.
Don’t look now, but Congress is examining ICD-10 implementation again.
The House Energy and Commerce Committee’s subcommittee on healthcare will hold a hearing at 10:15 a.m. Wednesday, February 11, on ICD-10 implementation. Chairman Joe Pitts (R-Pennsylvania) and other subcommittee members will hear from a “number of stakeholders” during the hearing. No word yet on who those stakeholders are. Witnesses will be announced and are by invitation only. You can watch the hearing webcast, though if you aren’t invited or can’t make it to D.C.
You may remember Pitts as the person who finally took credit for inserting ICD-10 delay language in last year’s Protecting Access to Medicare Act (PAMA). PAMA served as another patch to the Sustainable Growth Rate (SGR) payment reductions for physicians.
The subcommittee has been working on another permanent SRG fix, which would eliminate the yearly drama of “will they or won’t they put off the payment cuts again.” The subcommittee had a permanent fix last year, but it didn’t make it to law.
I am a little concerned about the makeup of the subcommittee that could once again derail ICD-10 implementation. The House Energy and Commerce Committee members include physicians who are interested in ICD-10 implementation for good or ill. In the past, the broader “doc block” in Congress has been very anti-ICD-10. They have used the flaming water skis and sucked into a jet engine, subsequent encounter, as examples of why ICD-10 is unnecessary, which doesn’t inspire confidence.
On the positive side, the Coalition for ICD-10 will hold a Congressional briefing the day before the subcommittee’s hearing. The Coalition for ICD-10 is a broad-based healthcare industry advocacy group, including organizations such as AHIMA and 3M, which supports the U.S. adoption of the ICD-10 coding standard. The briefing will include the following individuals:
- Edward Burke, MD, and Phillip Beyer, DO; Beyer Medical Group, Fredericktown, Missouri, discussing small rural provider readiness.
- David W. West, MD, medical director health informatics and business partners, Nemours Children’s Health System, revealing how a children’s health system plans to improve care for pediatric patients.
- Karen Blanchette, MBA, association director, Professional Association of Healthcare Office Management, reviewing new survey results on physician office cost by the medical office managers
- George Vancore, senior manager, systems integrator and business architect, delivery systems mandates and compliance, Florida Blue, talking about payer readiness and testing.
As an organization ACDIS has continuously supported ICD-10-CM/PCS implementation. You can read ACDIS Director Brian Murphy’s response to worries that another Congressional delay might sneak its way into legislation from November 2014. We know how much time and energy so many of you throughout the healthcare industry–from coders to CDI specialists to physicians–have put into ICD-10-CM/PCS preparedness. Although we know this effort ultimately will not be in vain, let’s hope we can put it to good use soon.
The draft ICD-10-CM Official Guidelines for Coding and Reporting state that “traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.” the tabular list note at the beginning of the Injury, Poisoning and Certain other Consequences of External Causes (S00-T88) tells coders to “use secondary code(s) from Chapter 20, External Causes of Morbidity, to indicate cause of injury.”
Codes within the T section that include the external cause do not require an additional external cause code. S codes describe various types of injuries related to a single body region, and T codes describe injuries associated with unspecified body regions as well as poisonings and certain other consequences of external causes. Although CDI Specialists have not typically queried for external cause codes (E codes in ICD-9-CM and V00-Y99 codes in ICD-10-CM) these combination codes will require additional documentation from the provider detailing the events surrounding the injury once the new code set implementation takes place.
Regarding the circumstances of the injury, when no intent is indicated, the default is accidental, according to the Official Guidelines for Coding and Reporting. Although the available codes include “events of undetermined intent,” they should be used only if the physician specifically documents that the intent cannot be determined.
In ICD-10-CM injuries are grouped by body part rather than by category. The organization aligns with how providers document injuries–often a systematic progression from head to toe after the most serious injury is assessed. The focus of treatment can be misleading to those without a clinical background or expertise coding traumatic injuries.
For example, a patient may be int he ICU for a neurological injury that requires a high level of nursing care and repeat imaging but if the coder does not review the nursing and imaging report, all he or she may notice is that an open fracture of the limb was treated with required antibiotics and surgical care.
Although the grouping changed from ICD-9 to ICD-10, the Official Guidelines for Coding and Reporting are similar, calling for separate codes for each injury unless a combination code is required. Remember that a code can only ever be reported once, so duplicate codes should never appear on a claim. Also, use of a combination code may require a query if the documentation does not already support use of a particular combination code. The Figure below illustrates some of the changes in the injury code set.
Our good friend, Michelle A. Leppert, over at the ICD-10 Trainer Blog took great pains (pun intended) this holiday season to chart out a selection of misadventures related to the traditional holiday theme song “The 12 Days of Christmas.”
On the first day of Christmas the house cat attacks the partridge in a pear tree which causes the bird to start hurling pears at the residents hitting our “true love” in the head.
On the second day, those turtle doves decided to spit seeds in his eyes and on the third day their two-year old decided to chase the three french hens, mimicking their flight and falling from the edge of the couch instead. On the fourth day, in an attempt to escape the fluttering onslaught of four calling birds our true love tripped on the coffee table and crashed through the sliding glass doors. Happily our hero decided to get golden rings for the fifth day. Unhappily little Andrew decided to see if one of them fit up his nose. It didn’t.
A host of other (hysterical as long as its fictional) mishaps ensue as the remaining seven days of holiday cheer come and go. We can’t imagine what the emergency room staff felt about all this. They must have called in the case management team for a little intervention at some point.
If you need any holiday-related excuses for a little ICD-10-CM/PCS coding review this collection of posts will help keep you chuckling while you do it.