by Patricia E. Brooks, RRA
HCFA conducted a formal test of ICD-10-PCS (procedure coding system)
in order to determine if it would be a practical replacement for the current
ICD-9-CM, Procedures. This coding system was developed after an open competition
contract was awarded to 3M/HIS. In order to avoid any conflict of interest,
HCFA asked two other contractors to evaluate the proposed ICD-10-PCS.
The contractors were two clinical data abstraction centers (CDACs)DynKePRO
in York, PA, and FMAS in Columbia, MD. The CDACs were charged with identifying
necessary revisions in the current draft of ICD-10-PCS, as well as evaluating
the training package with which their employees had been trained. Both
contractors found ICD-10-PCS to be an improvement over ICD-9-CM, as it
provided greater specificity in coding for use in research, statistical
analysis, and administrative areas. A major strength of the system was
its detailed structure, which allowed users to recognize and report more
precisely the procedures that were performed.
After an initial training curve, the CDAC coders were able to use the
system easily, with a few anticipated challenges. Because of added detail
in the new system, it was occasionally necessary for the coders to utilize
a medical dictionary or an anatomy textbook. Both HCFA and the CDACs recognize
that coders will require a greater understanding of anatomy and surgical
terms to use ICD-10-PCS than is required for ICD-9-CM. This would result
in a greater amount of training time than is currently the case. Although
the training manual as prepared under the contract was very useful, it
needs to be strengthened with additional examples before any national
training takes place. It was also suggested by the CDACs that the addition
of diagrams of the body systems would be useful in the training manual.
The CDAC coders quickly became proficient in the new system and were
able to suggest a number of improvements, such as additional index entries
and revisions to the body site and approach fields. These suggestions
were forwarded to 3M/HIS for inclusion in the final draft. This exercise
pointed out how easily the new system can be updated and expanded when
issues are identified. Another area of concern was correct code assignment
for records that did not provide enough documentation of a specific site
or the type of procedure, or when the coders did not have enough knowledge
of anatomy to select a precise code. Similar concerns arose about how
the system would address new procedures, since ICD-10-PCS did not provide
a Not Otherwise Specified (NOS)or Not Elsewhere Classified (NEC) code
as is present in ICD-9-CM. Many of the questions raised by the testers
after an initial period of training could have been addressed through
the addition of NOS/NEC codes.
Comparison of Two Systems
A side-by-side comparison of ICD-10-PCS and ICD-9-CM was performed when
the coders became proficient with the use of the new system. One contractor
reported that the staff did not detect a significant time difference in
using ICD-10-PCS as compared to ICD-9-CM. The other contractor found that
the ICD-10-PCS process took somewhat longer. ICD-10-PCS at times required
a greater number of codes than ICD-9-CM. This was due in part to ICD-9-CM's
use of more combination codes than ICD-10-PCS. However, it was felt that
the refined precision of ICD-10-PCS resulted in greater detail about the
nature of the procedure and was therefore worthwhile. It was suggested
that once coders became familiar with the greater detail and precision
of the new system, the result would be improved accuracy and efficiency
Both CDAC contractors pointed out that once the coders were familiar
with the new system, they rarely used the index. The ICD-10-PCS system
was found to be so well organized and so well structured that coders could
quickly find the correct section of the tabular list. The index was used
more often when the coder was just learning the definitions of the root
procedures and other basic terms used in the system. However, once coders
understood the system, they found it easy to code from the tabular section.
One of the contractors pointed out that the system had only been tested
on hospitalized patients. Since some hospitals currently code both inpatients
and outpatients with ICD-9-CM, the CDAC suggested that additional testing
should occur on outpatient records.
Major Revisions as a Result of Testing
The testers recommended a number of additions for the index and tabular
sections. As a result, one of the major revisions will involve adding
a NOS/NEC concept to ICD-10-PCS. As mentioned earlier, there was concern
that sufficient documentation may not be present in the medical record
to support the detail required by ICD-10-PCS. There was additional concern
that some coders may lack the knowledge of anatomy necessary to know where
a particular body part is located. To address this issue, the anatomic
detail was greatly expanded in the index. To address the issue of poor
documentation in the medical record, the number of approaches were reduced
from 17 to 13 and an NOS/NEC concept was added to the system.
As part of a contract awarded in 1994, the CDACs' primary task has been
to collect clinical data from about 1.5 million medical records over five
years. The primary end product of the CDAC contracts called for accurate
and reliable clinical data in quantities sufficient to support the analytical
efforts of the PROs as they carry out the Health Care Quality Improvement
Program. Since the CDACs had a ready supply of current medical records
and extensive experience in reviewing, abstracting, and coding medical
records, they were the logical selection to act as reviewers.
3M/HIS, the HCFA contractor who developed the new system, subcontracted
with Rita Finnegan, RRA, CCS, a Chicago-based private consultant, to prepare
an extensive training manual. The CDACs were trained for two days on the
medical/surgical part of the system, and a separate one-day session was
held for the remaining sections (nuclear medicine, radiation oncology,
osteopathic). The CDACs then spent several weeks coding with the system
to gain experience. Conference calls were held to answer questions prior
to the start of the formal testing.
In the first phase of the test, a sample of 5000 medical records (2500
per contractor) was chosen by the CDACs, identifying cases with a wide
distribution of ICD-9-CM procedure codes. The CDAC coded the cases using
ICD-10-PCS and noted any questions or concerns. These questions and other
issues were forwarded to 3M/HIS, which then responded on an ongoing basis.
As a result of this interaction, 3M/HIS made a list of revisions to be
made the final draft due to HCFA in March 1998. This included terms that
needed clarification and omissions in the tabular list of index sections.
In addition, areas where the training manual could be improved were identified.
In the second phase of the test, a subset of 100 medical records was
recoded blindly using both ICD-9-CM and ICD-10-PCS. By this time the CDAC
coders were quite experienced with the new system. The reviewers began
coding the first 50 records on ICD-9-CM, then moved to ICD-10-PCS. For
the last 50 records, they reversed the process and began with ICD-10-PCS.
The systems were to be compared on issues such as ease of use, time needed
to identify codes, number of codes required, problems identifying codes,
strengths and weaknesses of each system, and any other issues identified
by the coding personnel.
Patricia E. Brooks is the project officer of ICD-10-PCS at HCFA. She
was previously a commissioned officer of the US Public Health Service.
Brooks, Patricia E. "Testing ICD-10-PCS." Journal of
AHIMA 69, no. 5 (1998): 73-74.