Crossroads Conference
ICD-10 Industry Update
Susan H. Fenton, PhD, RHIA
Asst. Dean for Academic Affairs
UT School of Biomedical Informatics @ Houston
Agenda
Policy
• The delay
• ICD-11
• SNOMED
Practical impacts
• Clinical documentation
• Coding productivity
• Quality Measures
The Delay
• H.R. 4302
• SEC. 212. DELAY IN TRANSITION FROM ICD–9 TO ICD–10
CODE SETS. The Secretary of Health and Human Services
may not, prior to October 1, 2015, adopt ICD–10 code sets as
the standard for code sets under section 1173(c) of the Social
Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of
title 45, Code of Federal Regulations.
• $1 billion to $6.6 billion additional – CMS
Latest Update
“On April 1, 2014, the Protecting Access to Medicare Act of 2014
(PAMA) (Pub. L. No. 113-93) was enacted, which said that the
Secretary may not adopt ICD-10 prior to October 1, 2015.
Accordingly, the U.S. Department of Health and Human Services
expects to release an interim final rule in the near future that will
include a new compliance date that would require the use of ICD10 beginning October 1, 2015. The rule will also require HIPAA
covered entities to continue to use ICD-9-CM through September
30, 2015.”
Provider Responses
Part B News, 73% of providers plan to stick with their original ICD-
10 implementation plans, despite the delay, EHR Intelligence
reports (Bresnick, EHR Intelligence, 4/24).
How providers feel about the delay. Specifically:
• 34% of organizations ready but appreciate additional time;
• 31% of organizations disappointed with the delay;
• 20%+ of organizations frustrated because physicians now might want to
delay training; and
• 13.5% of organizations happy with the delay because they would not have
been ready otherwise (Marbury, Medical Economics, 4/23).
CMS ICD-10 Claims Submission Testing
Conducted in March 2014
• 2,600 participating organizations; 50% were
clearinghouses
• 127,000 claims submitted with ICD-10-CM/PCS
codes
• 89% of claims were accepted
• Some claims included intentional errors to ensure the
system would reject appropriately
Contact local MAC for acknowledgment
testing details
More end-to-end testing in 2015
ICD-11
Release delayed to 2017 – WHO
Derived from SNOMED
Compatible with EHRs
Participate @
http://www.who.int/classifications/icd/revision/icd1
1faq/en/
SNOMED
Focused on clinical information
Compatible with EHRs
311,000 active concepts
33% agreement on core concept choice
• Andrews, J.E., Richesson, R.L., and Krischer, J.
(2007) SNOMED CT Coding of Clinical Research
Concepts, Journal of AMIA, 14(4), 497-506.
So, why move at all?
• Public health
• Quality patient care
• Research
• Reimbursement
Clinical Documentation Improvement
• Laterality: No longer accept injuries to limbs or
bilateral organ conditions without laterality.
• Paralytic syndromes require right/left and
dominant/nondominant
• Infectious organisms. How can we help
clinicians include these in their documented
diagnoses?
Injuries
• A for Initial Encounter – active initial treatment
in ER, surgery or new clinician
• D for Subsequent – healing or recovery such
as cast change or aftercare
• S for Sequela – complications or conditions as
a direct result of the injury. Examples include
scars or frozen joint
Fractures
• Open, including Type vs. Closed
• Routine vs. Delayed healing
• Nonunion vs. Malunion
• Displaced vs. Nondisplaced
• Many types, transverse, comminuted, or spiral
to name just a few
Clinician-specific Efforts
Track use of unspecified codes by clinician
•Appropriate or not?
Random coding of records in ICD-10-CM/PCS to
determine adequacy of documentation
•Feedback
•Evaluation criteria
Inpatient Coding Productivity
• 54 records
• 6 coders
• ICD-9-CM Avg Coding Time – 25.51
• ICD-10-CM/PCS Avg Coding Time – 43.23
• Overall on average it took 17.72 minutes or
69% longer to code a record in ICD-10CM/PCS
Coding Quality or Inter-rater Reliability
• ICD-9-CM Diagnostic = .68
• ICD-9-CM Procedural = .61
• ICD-10-CM = .49
• ICD-10-PCS = .42
Quality vs. Minutes/Record
• Spearman’s Correlation
•Correlation Coefficient = -.424
•P-value = .027
• As the time spent per record increases, the
coding quality decreases
Veterans Health Administration
Inpatient Coding Productivity
• 382 inpatient records
• 65% decrease in productivity
• 12.5 minute decrease without procedures
• 20 minute decrease with procedures
• Non-OR procedures accounted for longest
Veterans Health Administration
Ambulatory Coding Productivity
• 1,024 ambulatory care records
• 6.7% decrease in productivity
• Longest time to code ER and Therapy
• Productivity recovered within 2 months
Comparability Factors or Ratios
• Comparability, aka bridge-coding, for longitudinal
data comparison
• Performed for ICD-9 to ICD-10 for Cause of Death
• http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_02.
pdf
• Must dual code same set of records
• 𝐶𝑖 = 𝐷𝑖 ICD10 𝐷𝑖 (ICD9)
Calculating the Comparability Factors
• Frequencies run for ICD-9-CM and ICD-10-CM
diagnostic codes
• Used the 2013 General Equivalence Maps
• Used the July 2, 2013 National Hospital Inpatient
Quality Measures, Appendix A (ICD-9) and Appendix
P (ICD-10)
Joint Commission Core Measure
Comparison (ongoing analysis)
Missing ICD-9-CM Cases for AMI
I21.02 – STEMI
I21.4 – Acute
involving diagonal subendocardial
coronary artery
MI
410.72 –
Subendocardial
infarction
410.12 – AMI of
other anterior
wall
6
1
Extra ICD-9 Cases for Respiratory
Failure
J96.01 – Acute
hypoxemic
respiratory
failure
518.81 – Acute
Respiratory
Failure
27
J96.02 – Acute
hypercapnic
respiratory
failure
4
In the Final Analysis
• Implementation now slated for 10/1/2015
• Review insurance and vendor contracts
• More time for system upgrades
• Continue documentation improvement
• Maybe consider Computer-assisted Coding
• Identify potential longitudinal data concerns
Questions
Thank you to Texas Tech and the West Texas AHEC.
Contact Information
• Susan H. Fenton, PhD, RHIA, FAHIMA
• Assistant Dean, UT SBMI
• susan.h.fenton@uth.tmc.edu