By Judy A. Bielby, MBA, RHIA, CPHQ, CCS, FAHIMA
In 1986, a classroom full of medical record administration students learned that the world would soon transition from ICD-9 to ICD-10. The instructor noted that ICD-10 was expected to be completed in about three or four years and that a clinical modification for use in the United States would soon follow. That estimate was not too far off in regards to the World Health Organization’s (WHO’s) ICD-10 release date. But no one could ever have imagined how long it would take to replace the United States’ ICD-9-CM diagnosis and procedure codes with the new code sets.
In 2015 the US transitioned from ICD-9-CM diagnosis and procedure codes to ICD-10-CM and ICD-10-PCS codes. It should be noted that WHO’s ICD-10 has been used in the US to classify mortality data from death certificates since 1999. It took many more years, however, for the US to switch from ICD-9-CM to ICD-10-CM and ICD-10-PCS for reporting diagnoses and inpatient procedures in healthcare settings.
ICD-10-CM/PCS is Here—What is the Impact?
The good news is that hospital and patient care operations did not grind to a halt on October 1, 2015. Payers and providers alike were quick to report in the earliest stages of the transition period that, overall, the transition was going smoothly. Minor issues with interfaces between computer systems were reported and addressed either immediately or within a couple of weeks. Many physicians reported that the transition from ICD-9-CM to ICD-10-CM went smoothly, but other physicians reported turbulence. Some clearinghouses were not as ready as they said they would be, while others were well-prepared.
Overall, the extensive efforts by many in preparing for the transition appeared to pay off, particularly those who continued their efforts to prepare even when the implementation was delayed. “Successful testing of claims transmission was the result of extensive work from many entities including our business partners in patient accounts, clearinghouse, and EMR as well as our IT and revenue divisions,” says Norma Knipp, MHSA, RHIA, CHPS, health information director and privacy officer at North Kansas City Hospital. “The additional year allowed the business partners to fine-tune their products based on previous testing results.”
Many health systems established emergency help lines for physicians and hospital employees to call regarding ICD-10 implementation issues, but some organizations found that such help lines were not as necessary as expected. “Due to concern on the part of physicians over the impact that ICD-10 would have on their day-to-day processes, a command center was established that would be staffed from October 1 through the 15th to provide a direct line of support,” says Seth Jeremy Katz, MPH, RHIA, assistant administrator, information management and program execution at Truman Medical Centers in Kansas City, MO. “By noon on October 2, due to the lack of phone calls or identified problems, the command center was folded.”
As expected, the transition has had an effect on the revenue cycle. Coding productivity has significantly decreased at facilities across the country. In some cases the impact was not as much as expected, and in other cases the impact was greater than expected. Coding productivity has decreased more for ICD-10-PCS coding than for ICD-10-CM coding. Productivity is expected to improve over time with the adoption of technology such as computer-assisted coding and with increased experience in coding with ICD-10-CM/PCS.
One of the more significant issues to arise from implementation of ICD-10-CM/PCS stems from applicability of some ICD-10-CM codes for some of the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Centers for Medicare and Medicaid Services (CMS) officials have taken steps to address these issues. Questions about specific NCDs and LCDs should be directed to the appropriate Medicare Administrative Contractor (MAC).
The denials did not increase significantly in the first couple of months after implementation, but it is anticipated by some that over time the number of denials will slowly creep upwards. Many entities are closely monitoring claims and denials on a continuous basis, particularly focusing on claims that were rejected because of ICD coding issues. For the period of October 1 through October 27, 2015, CMS reported that 10.1 percent of total claims processed were denied compared to a historical 10 percent total claims denial rate. Approximately 4.6 million Medicare claims are submitted per day.1
ICD-10-CM/PCS Not Without Its Challenges
Not surprisingly, ICD-10-CM was easier to learn for experienced coding professionals than ICD-10-PCS. Even so ICD-10-CM is not without its challenges. Hot topics in the early months of ICD-10-CM coding were Excludes1 notes, seventh characters for injury and external cause coding, tobacco use/dependence, osteoarthritis, coding for rehabilitation and other post-acute care settings, and coding of wound clinic diagnoses.
In the first few weeks after ICD-10-CM was implemented, many coders struggled with how to locate an external cause code for lifting, twisting, or repetitive movement. In ICD-9-CM such occurrences were indexed to ICD-9-CM category E927, Overexertion and strenuous and repetitive movements or loads. However, the ICD-10-CM External Cause of Injuries Index references the coder to select a code from the ICD-10-CM category Y93 activity codes instead of a code that captures that the injury was caused by overexertion or strenuous movement. Certainly, a code from category Y93 should be reported, but it is not the only external cause code that should be reported.
Like others, Natalie LaBoube, RHIT, data quality specialist at a health system in the Kansas City, KS metropolitan area, researched potential ICD-10-CM code equivalents to the codes found in ICD-9-CM category E927. It appears that this issue is being addressed with a proposal to add category X50, Overexertion and strenuous or repetitive movements. This new category will include 12 new codes describing overexertion, strenuous movements, and awkward postures.
ICD-10-PCS is very different from ICD-9-CM procedure codes. One aspect of ICD-10-PCS that many coding professionals find challenging are the various types of approaches for procedures reported with codes from the ICD-10-PCS Medical and Surgical Section. The approach value assigned for a procedure—whether it is an open, percutaneous, or other type of approach—can significantly impact DRG assignment, so it is important to have a good understanding of the definitions for each of the approach values. Many coders find it useful to have a readily accessible tip sheet with definitions of each of the approach values in the Medical and Surgical Section along with relevant official coding guidelines and some examples.
Professional coding help is also readily accessible. AHIMA’s Code-Check™ is made up of credentialed, experienced coders and provides guidance on code assignment. According to Gina Sanvik, MS, RHIA, AHIMA-approved ICD-10-CM/PCS trainer and a director of HIM practice excellence, coding and data standards, at AHIMA, the majority of questions submitted to Code-Check pertain to ICD-10-PCS and are cardiovascular related. “No questions are beginning level questions, they have all been intermediate and advanced questions,” Sanvik says of the questions that have been submitted to Code-Check.
There’s Still Work to Be Done
ICD-10-CM/PCS codes are now being reported, but that does not mean that the work is finished for those involved in the transition process. Now more than ever there is a need for close monitoring of the coding and revenue cycle processes. Hospitals and other systems need to closely monitor case mix index, coder productivity, discharged not final billed (DNFB), coding quality, days to payment, reimbursement rate, rejection rate, denials, query rate, and other metrics. Issues that are identified need to be addressed as quickly as possible.
Coding accuracy is very important. Even if a facility or provider has not experienced a noticeable decrease in productivity, it shouldn’t be assumed that all is well. First, they should take a critical look at why productivity has not been reduced. While efforts with education and dual coding will certainly improve productivity, there might be unexpected reasons why productivity was not reduced. Are coders assigning the correct codes? Only quality work is productive work. Be sure to monitor coding accuracy as well as coding productivity. Ongoing continuing education for coders is very important.
Some of the same issues that clinical documentation improvement specialists saw with ICD-9-CM continue to be issues in ICD-10-CM. New documentation issues have been identified with ICD-10-CM and ICD-10-PCS. In addition to clinical documentation improvement programs, strong information governance programs are critical for managing information as a key asset. These efforts will support a successful transition to ICD-10-CM/PCS because accurate code assignment depends on reliable documentation in the patient health record.
Post-ICD-10-CM/PCS Implementation Resources Available
There are multiple post-ICD-10-CM/PCS implementation resources available from AHIMA, including:
Additional resources are available at www.ahima.org/topics/icd10/faqs.
 Centers for Medicare and Medicaid Services. “Fact Sheet: ICD-10 Transition Moves Forward.” October 29, 2015.
Centers for Medicare and Medicaid Services. “Clarifications about National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).” November 2015.
Judy A. Bielby (email@example.com) is a clinical assistant professor at the University of Kansas Medical Center School of Health Professions, Health Information Management Program, and a consultant with Durst and Associates.
Bielby, Judy A.
"Continuing on the Intriguing ICD-10 Journey"
Journal of AHIMA