ICD-10: An Update on the Worldwide Implementation--the Australian Experience

Rosemary Roberts MPH, MBA

Background and History

Australia implemented ICD-10 for mortality reporting in 1998 and completed its implementation for morbidity reporting in 1999. A useful summary of the process was summarised in an article published in the Journal of AHIMA in January 2000.1

Australia has a long-standing culture of collection of morbidity data to describe diseases and procedures relating to hospital inpatient episodes of care. It has followed the United States of America in use of the Standard Nomenclature of Diseases and Operations, ICD-8, ICD-9, and ICD-9-CM. Use of the data was for research, monitoring trends in utilisation of hospitals, epidemiological and public health studies, and for audit and quality assurance studies.

In 1994, the National Coding Centre (NCC) (now the National Centre for Classification in Health [NCCH]) was established to ensure that Australia used national standards for coding and reporting diseases and procedures. The main driver for the creation of the centre was the use of the data for casemix grouping and funding. Our first task was to prepare an Australian version of ICD-9-CM, which related to the Australian system of Diagnosis Related Groups, at that time the Australian National Diagnosis Related Groups. Australia published two editions of ICD-9-CM, implemented in July 1995 and July 1996.

One of the other initial requirements of the NCC was to produce an options research paper on the future long term suitability of using the ICD-9-CM in Australian Hospitals. This paper, published in June 1994, weighed the options of remaining with ICD-9-CM and waiting for ICD-10-CM or plans to change to ICD-10 as soon as possible. The change to ICD-10 also involved developing or adopting a new procedure coding system.

Another factor in the history of ICD-10 implementation was the use of ICD for cause of death coding by the Australian Bureau of Statistics (ABS). The National Reference Centre for Classification in Health, established in Brisbane in 1992, had been undertaking classification activities in support of the Western Pacific Collaborating Centre for Classification of Diseases and had been charged with ICD-10 education in the region. One of its functions was to assist the ABS in implementation of ICD-10 for mortality coding and to support the Australian Institute of Health and Welfare (AIHW) in its role as WHO Collaborating Centre.

The options paper made several recommendations. The first critical one for this discussion was that the National Coding Centre and National Reference Centre for Classification in Health be merged to consolidate resources for training and introduction of ICD-10 in Australia. The idea was to bring together efforts to use ICD-10 for mortality and morbidity reporting purposes.

A second recommendation from that paper was to adopt ICD-10 as the national system for morbidity coding and to embark on a project to determine the most appropriate procedure classification to be used with ICD-10 in Australia.

Methods

The Australian government accepted the recommendations made in 1994, and plans were set in train to merge the two centres, to develop a modification of the ICD-10 disease classification, and to decide on an appropriate procedure classification.

The first step was to obtain a licence for the Australian government from the World Health Organization (WHO) to derive a clinical modification of ICD-10.

Also, a mapping was done between ICD-10 diseases and ICD-9-CM to highlight the changes and inform areas of ICD-10 requiring further modification and specificity. The NCC marshalled health information management expertise within the organisation and established a wide network of external clinical groups to advise and inform development of the classification. These groups comprised clinicians, HIM professionals, and clinical coders.

The NCC embarked on development of an Australian Modification of ICD-10 diseases, involving changes to the tabular list sanctioned by WHO and embellishment of the alphabetic index. An important part of ICD-10-AM, as it came to be called, was the creation of Australian Coding Standards, which form an intrinsic part of the classification. A careful evaluation of procedure classifications was undertaken.

The Australian Health Ministers Advisory Committee established a high level national committee to oversee the implementation of ICD-10. The committee was made up of key stakeholders from the commonwealth (Health, Veterans Affairs) and state jurisdictions, professional organisations, the private sector (hospitals and insurers), the ABS and AIHW, and of course staff members from NCC and NRCCH. It held 14 meetings between 1995 and 1999.   It also seconded from time to time with other special interest groups who were involved on an ad hoc basis, for example, cancer registries. A respected medical practitioner with a national profile chaired the committee. A national coordinator of ICD-10 implementation was appointed in the Australian Department of Health.

A major education plan was developed and carried out during the implementation phase. NCC coordinated the ICD-10-AM Education Working Party, which was charged with developing education, and marketing plans for the new classification. It held 11 meetings between 1996 and 1999. Members were drawn from educational institutions providing undergraduate programs in health information management and clinical coding courses, from professional organisations (HIM and clinical coding), and the NCCH. While education was mainly geared towards users of classification and coding tools at the hospital level, users of coded data and commercial vendors of coding systems were also targeted.

An ICD-10-AM Implementation Kit was developed and published by NCCH. Its aim was to inform ICD-10-AM users and to provide them with material to educate staff within their own departments and hospitals on the implementation process.

Financial resources for these committee activities and for resulting NCCH functions were sought from and provided by the Australian government. However, participation in many of the meetings was supported by the state and territory jurisdictions, educational and professional organisations, and by the many other stakeholders involved.

NCC was involved in a parallel National Coder Workforce Issues Project funded by the Australian government and headed by the Health Information Management Association of Australia. This project identified at a national level the human resources currently involved in coding functions and the needs of clinical coders, managers, and employers in regard to education and accreditation.

The Department of Health also commissioned a dual coding study to assess the impact of change from ICD-9-CM to ICD-10-AM. The study, carried out by Coopers and Lybrand in 1997 with input from NCCH and clinical coders, assessed the change in time taken to code, personnel, education, and IT requirements and assessed the overall cost of change.

Results

In 1997, the Australian mortality and morbidity aspects of ICD-10 development and use were merged by creation of a joint venture relationship between universities in Brisbane and Sydney to form the National Centre for Classification in Health. This consolidated the ICD-10 expertise for Australia and the region into one centre.

A licence for use of Australian government use of ICD-10 was obtained from WHO. It allowed changes to the classification at the fifth character level and recommended that suggested changes at the third and fourth character level be discussed with WHO. It did not allow change in meaning of the existing rubrics. A clinical modification of the ICD-10 classification of diseases was prepared and released as ICD-10-AM First Edition in 1998.

A decision was taken to develop an Australian procedure classification to accompany the clinical modification of ICD-10. It was created from the Australian fee schedule, the Medicare Benefits Schedule, and is based on traditional classification principles of body system, site, procedure type, and approach. Known as the Australian Classification of Health Interventions (ACHI), the procedure classification forms part of ICD-10-AM.

ICD-10-AM First Edition had a staged implementation with half the country implementing in July 1998 and the other half in July 1999. Since then, all states and territories have updated together, and there is agreement through the National Health Information Group for standard implementation so that the national morbidity data set is expressed in the same edition.

Trends

Since its release in 1998, ICD-10-AM has been updated biennially. ICD-10-AM Fourth Edition has been released and is due for implementation in July 2004.

NCCH realised that for efficient maintenance and production of classification systems, a database of the content of ICD-10-AM was necessary. This was built for ICD-10-AM Second Edition and has been the cornerstone of operations ever since. It enables us to publish hard copy and electronically. A recent innovation has been the production of an eBook, an electronic representation of the book with hyperlinks between terms, codes, and standards. The latest version can be networked and has provision for individual and shared notes.

Coder support has been an important component of NCCH function. Queries are handled firstly by state and territory coding committees. Issues that cannot be solved at that level are sent to NCCH for discussion with expert clinicians and coders, to gain agreement, and to disseminate the outcome. NCCH maintains a query database and posts the queries and the answers on its Web site. The database is searchable so that coders can access issues of interest. A coding newsletter, Coding Matters , is published quarterly, with the 10-AM Commandments bringing coders up-to-date on contentious issues, which then become incorporated, in the next edition of
ICD-10-AM.

Discussion

Many of the issues discussed above are not peculiar to ICD-10 and its implementation. However, introducing ICD-10 has highlighted the need to keep the classification vibrant and credible, and its use as the foundation for the Australian casemix system, the Australian Refined Diagnosis Related Groups, has meant a much broader and more interested group of stakeholders.

NCCH is indebted to its expert and advisory committees for their contribution to the acceptance of the classification and its successive editions. Every attempt is made to gain agreement before changes are made so that implementation is relatively smooth. Australia has an excellent coder workforce of trained coders, but of course, there are never enough coders nor education programs to satisfy the thirst for knowledge to improve skills in abstracting and coding.

Many of the individuals on our initial and ongoing clinical coding and classification groups also advise the Australian government in its DRG refinement process. This means that knowledge and skills that had not previously existed are built up among clinicians, and communication with clinical coders at all levels is improved. It also helps the clinical coders to have a thorough understanding of the relationship between coding and casemix, which changes their role at the hospital level and provides another dimension to their functioning and understanding of the classification.

Conclusion

ICD-10 implementation has provided a turning point for Australian health information managers and clinical coders. It has meant that the NCCH has had to learn very quickly about the intricacies of creating a clinical modification of a disease classification and about how to build a procedure classification from first principles. It has lead to a real appreciation of the skill of those who built ICD-10 and of those responsible for its maintenance. For Australia, it has brought us closer to WHO and resulted in involvement from NCCH staff in the WHO ICD-10 Update Reference Committee.

ICD-10-AM is being used in whole or in part in other countries outside Australia, for example New Zealand, Germany, Romania and next year, in Ireland. NCCH regards this as a great compliment and also a responsibility to continue to improve the classification to meet users needs.

Our next challenge is to relate ICD-10-AM to clinical terminologies. The classification itself, as we know, is built from clinical terms, but it is a real challenge to translate clinical concepts and terms attached to them to classification rubrics in a logical and disciplined way, incorporating the rules and conventions of ICD and the Australian Coding Standards. Going one step further and representing these rules electronically will bring us to the next plane and allow a transparent connection between terms used in electronic health records and their classification so that information can be exchanged and reported.

Endnote

1Innes K, Peasley K, Roberts R. "Ten Down Under: Implementing ICD-10 in Australia." Journal of AHIMA January 2000, 71/1, 52-56.

About the Author

Rosemary Roberts MPH, MBA, is the director of the Australian National Centre for Classification in Health at the University of Sydney, Queensland University of Technology and La Trobe University Melbourne.


Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004