So What Was Wrong With ICD-9?

The Great ICD-10 Debate: Healthcare Coding Transforms

We're admonished to avoid cliches and platitudes, but some contain too much wisdom to ignore. "Not seeing the forest for the trees" is one of the best.

As IT departments struggle to put the ICD-10 coding system in place in various health information systems, CIOs and chief medical information officers (CMIOs) should prepare for a barrage of complaints about all the extra work that clinicians will be required to do.

ICD-10, which stands for International Classification of Diseases, 10th Edition, contains the codes used to bill insurers for a variety of diagnoses and inpatient medical procedures. The currently used ICD-9 contains 13,000 diagnostic codes, while version 10--due to be implemented by October 1, 2014, if the feds don't change their minds again--has 68,000. ICD-9 has 11,000 procedure codes, compared with 87,000 in ICD-10. That sure sounds like a lot more work.

Critics of the new system complain that it's so granular it's almost laughable. According to a Wall Street Journal article, in an attempt to refine the billing process for patient injuries, there are now specific codes depending on whether the injury occurred in an opera house, in an art gallery, around a mobile home, even in a chicken coop. There are also codes to specify if the patient was hurt while sewing, ironing, playing a brass instrument, or knitting.

Clinicians scoff at such granularity. What difference does it make to Dr. Jones if he's treating a bump on the head that occurred while the patient was listening to Don Giovanni or viewing a Picasso painting? This gets back to the trees and forest analogy.

[ For additional insights on the ICD-10 debate, see our new slideshow The Great ICD-10 Debate: Healthcare Coding Transforms. ]

Clinicians' top priority has always been to treat individual patients--the trees. But as the role of medical informatics and data analytics grows, doctors must start thinking not just about the patients in front of them, but about the population as a whole--the forest.

Much of the granular data generated from ICD-10 can be analyzed and used to do population surveillance. It can help policymakers determine public health campaigns and detect epidemics before they get out of hand. And the new coding system will also provide a treasure trove of data for public health researchers as they try to understand patient behavior and attitudes about risk taking. So, yes, knowing where specific types of injuries occur on a farm, for example, has merit.

Of course, some physicians will object to the fact that they now have to not only provide care for their patients, but also take on this public health role. They can take some comfort in knowing their IT counterparts are in the same boat.

IT managers now must make major adjustments to a host of programs, despite the fact that their organizations aren't public health agencies. They must make sure their financial applications are ICD-10-compliant. Other applications must be able to extract these codes, moving them through the system so that providers will be reimbursed.

Still, the really scary part of ICD-10 implementation, according to George Brenckle, CIO for UMass Memorial is: "Does my clinical documentation have enough detail in it to support the appropriate coding?" In other words, are my doctors providing enough detail in the electronic health record (EHR) system to meet the demands of ICD-10? "Our clinicians are just not used to providing that level of detail in their notes," Brenckle says.

Obviously, there's lots of angst to go around as hospital and medical practices struggle with ICD-10. And stakeholders will likely debate the merits of the system for some time.

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