Thursday
August 12, 2004
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| Nelly Leon-Chisen |
A patient is admitted with a 428.0 and a 401.9, and a 00.50 is performed. Your hospital is paid on a 116 based on these codes. What are all these numbers? They're ICD-9-CM diagnosis and procedure codes that, when reported in certain combinations, result in specific diagnosis related group (DRG) payments. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is probably something that you don't give much thought to--unless you're a coder or biller. These codes are the key to a hospital's inpatient reimbursement.
ICD-9-CM has been around for nearly 25 years. Think of all the advances in medical knowledge and the new diseases discovered in that time. No one would have dreamt then about inserting a thin wire into a patient's neck, threading it slowly until it reached the patient's brain, then using the wire to fill a defective pouching of a vessel. Yet these procedures are being done today.
ICD-9-CM has been revised and expanded to the point where the classification is now running out of space and numbers for new diseases and procedures. Some categories have vague and imprecise codes. Because of a lack of space in the classification, several distinct procedures performed in different parts of the body--with widely different resource utilization--may be grouped together under the same procedure code. This lack of specificity prevents accurate data collection on new technology, increases requirements for submission of documentation to support claims, creates a lack of quality data to support health outcomes and leads to less accurate reimbursement.
Less accurate reimbursement is a serious problem indeed when new devices are not recognized--or even more critical, when the system can't distinguish between an injection, insertion of a therapeutic substance or interventional radiology brain procedure. For example, code 99.29 (the code for "injection or infusion of other therapeutic or prophylactic substance") has been used to report a wide variety of procedures, including an injection of epinephrine to cauterize a rectal ulcer, infusion of a narcotic into a pump for pain relief, insertion of an implant in the eye for slow release of an antiviral drug, injection into the uterine artery to treat a fibroid and, before the creation of a unique code, insertion of a wire coil into the brain vessel. Such poor differentiation in the coding also makes future payment rate setting difficult, and accurate information is not available for statistical analysis in public health, benchmarking or outcome analysis.
Hospital coders find it difficult to "squeeze" current procedures into unspecified or ambiguous codes. A couple of years ago, the Centers for Medicare & Medicaid Services (CMS) examined ICD-9-CM to identify an open series of codes that could be used as a short-term solution for new technologies and procedures. These code numbers won't last long either.
Improvements in medical technology have made it possible to combine conventional pacemakers and internal cardioverter-defibrillators (ICDs) into a single device. Two years ago, CMS created five new codes to report services related to these new devices. Before the new codes, coders were faced with a dilemma: Should they use two codes--one for the pacemaker and one for the ICD device insertion (so that it looked like two separate devices were inserted)? Or should they report only one code--either the pacemaker insertion or the ICD insertion (missing out entirely on one aspect of the procedure)? The new devices also cost many times more than the conventional technology. Vague and confusing codes increase the risk of coder errors and the potential for fraud and abuse allegations when codes don't match the more current physician terminology in the records.
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Classification System (ICD-10-PCS) have been developed as a replacement for ICD-9-CM. ICD-10-CM consists of a clinical modification of the World Health Organization's ICD-10. ICD-10-CM consists of diagnosis codes, while ICD-10-PCS consists of procedure codes.
Implementation dates for ICD-10-CM and ICD-10-PCS have not been set. The National Committee on Vital and Health Statistics (NCVHS), the advisory committee to the Secretary of Health and Human Services, has been studying the problems with the existing ICD-9-CM classification system since the 1980s.
A 2003 cost-benefit study commissioned by the NCVHS from the RAND Corporation concluded that the benefits of ICD-10 implementation far outweighed the costs. The study projected the following benefits:
In November 2003, the NCVHS issued a recommendation to the secretary to implement ICD-10-CM and ICD-10-PCS. A federal regulatory update to the Health Insurance Portability and Accountability Act (HIPAA) electronic transactions and code set standards is required for a change to either ICD-10-CM or ICD-10-PCS.
For organizational providers, implementing new coding systems primarily involves two types of costs: coder training and information system changes. Hospitals need to plan for the transition to ICD-10-CM for both inpatient and outpatient services, and to ICD-10-PCS for inpatient services. All other providers, such as physicians, home health agencies, skilled nursing facilities and postacute care settings, will be affected by a change to ICD-10-CM only, as ICD-10-PCS is being contemplated only for reporting inpatient services by hospitals.
The bulk of the costs for implementing ICD-10-CM and ICD-10-PCS will be for training personnel so they can become familiar with the new coding guidelines, rules and definitions. Support staff such as coders and billers as well as any others involved in coding or reviewing coding information will need training. Hospitals will need to work with their medical staff to ensure that appropriate documentation is available to support the new coding system. ICD-10-PCS code selection requires that more specific and detailed physician documentation be available in the medical record. This greater level of specificity may also require that coders and billers expand their knowledge of medical terminology, anatomy, physiology and disease processes.
There will be expected loss-of-productivity issues as coders take time away from coding to familiarize themselves with the new coding system. Many hospital coders already attend approximately 16 hours of training during the year to keep their coding skills current. It is assumed that these training costs will be replaced by costs associated with learning to use ICD-10-CM and ICD-10-PCS. However, current training for ICD-9 is spread throughout the year, while training for ICD-10 is likely to require bigger blocks of time. Coding productivity will lag while coders become proficient in the new system.
Changes to ICD-10-CM and ICD-10-PCS will also require extensive modifications to information systems. These will vary from software changes to data-field expansion, timing and data-conversion planning. Hospitals and other providers will need to perform an inventory of existing databases and information systems to determine the impact on their operations. Collaboration among departments will be necessary to identify these systems. Hospitals should conduct a systems inventory to determine where databases exist, what software is available and whether the software is from a commercial vendor or a homegrown or proprietary program unique to the facility. Senior managers and information systems staff should be aware of the imminent transition to a new coding system so they can plan software and hardware accordingly.
Some providers have started making changes to their systems, and some of their commercial vendors have already done the work. Others are waiting for more formal direction from the Department of Health and Human Services before making plans. Taking advantage of the lead time will ease the transition process once a migration decision is published.
Commercial software. Hospitals use a combination of purchased software and applications developed in-house. Physician offices also rely on purchased software, although some may have homegrown programs. The software applications that will require modification encompass functions such as code assignment, medical records abstraction, aggregate data reporting, utilization management, clinical systems, billing, claim submission, groupers and other financial functions. In essence, every electronic transaction requiring an ICD-9-CM code will need to be changed. These alterations include software interfaces, field-length formats on screens, report formats and layouts, table structures holding codes, expansion of flat files, coding edits and significant logic changes.
A migration to new coding systems such as ICD-10-CM and ICD-10-PCS will be a regulatory change. Most large health information system (HIS) vendors build the costs of regulatory changes into their user maintenance fees, so providers do not expect to incur additional costs for programming changes related to ICD-10. However, providers anticipate that, as a result of increased maintenance costs, they will see maintenance fees rise in the future.
Most maintenance contracts have a clause that covers regulatory changes. Some providers have already been working with their commercial vendors to determine their system's capability for accepting new codes. Many large HIS vendors have indicated that they are ready to accept ICD-10-CM codes (because of Canadian or other international implementations), or that the field lengths have already been increased in anticipation of a migration to ICD-10-CM and ICD-10-PCS.
Homegrown and proprietary software. There is some variation among hospitals and other providers in homegrown and proprietary software. The majority of hospitals have been moving away from homegrown systems in the last few years because of the expense and lack of sufficient information systems and technology personnel to maintain a homegrown system. University-based or large research centers may have more proprietary systems built for a specific application or research project than small or medium-sized urban or rural hospitals.
Large hospital systems may have commercial applications, but they may also have proprietary billing systems or billing edits specific to their hospitals. Some of the homegrown systems may have smaller databases built by a department using a PC-based application and Excel or Access.
Several different software applications use ICD-9-CM codes. Examples of hospital software applications that would be affected by a change to ICD-10-CM and ICD-10-PCS may be found in the figure below.
Hardware. During the transition period, information systems software will have to support ICD-9-CM, ICD-10-CM and ICD-10-PCS coding systems, potentially requiring additional data storage. Some hospitals have already started expanding the field size for the diagnosis and procedure fields based on the HIPAA Transaction Standard Notice of Proposed Rulemaking that mentioned ICD-10 as a future possibility.
Neither the field-size expansion nor the larger number of codes is considered to be a problem with today's systems. It is a small pocket compared with the rest of the database. Validation rules may take up more room in the system, but experts don't anticipate requiring more CPU or disk space. Twenty years ago, the larger field size and more codes would have been a problem, but disk capacity is inexpensive now, and CPUs are cheaper, too.
Providers will have to make decisions regarding conversion of existing ICD-9-CM data. After conducting an inventory of the applications using ICD-9-CM codes, providers should perform a cost/benefit analysis to determine which databases would need to be converted. More than likely, a combination of old data conversion on an as-needed basis, with some up-front conversion immediately before implementation of ICD-10, would work best.
Other providers may consider it easier to run a report in ICD-9-CM and a separate report in ICD-10-CM or ICD-10-PCS, then add up both reports manually--therefore negating the need to perform a full conversion of the database.
Changing to a new coding system will require planning and coordination involving not just the coding and health information management functions, but also clinical, billing, administrative and information technology staff. Making this change will be challenging and will require careful timing. However, the upgrade to a new coding system is expected to bring coded and reported data in line with the improvements in medical technology today and into the future.
Nelly Leon-Chisen, R.H.I.A., is the director of coding and classification at the American Hospital Association. She is also a contributor to the 2005 edition of ICD-9-CM Coding Handbook,published this month by AHA Press (www.ahaonlinestore.com).
Figure: Examples of Hospital Applications Affected by the Switch to ICD-10-CM and ICD-10-PCS
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