The Great ICD-10 Debate: Healthcare Coding Transforms

Healthcare's move to ICD-10, an updated set of diagnosis and inpatient procedure codes, will affect everything from billing systems to medical records. After several delays, debate still rages on how to time the transition.




The U.S. transition from the International Classification of Diseases Revision 9 (ICD-9) to ICD-10 has been underway for years, with a couple of deadline extensions adding to the timeline. The most recent deadline delay is a bit of a reprieve for overworked ICD-10 transition teams, as long as organizations don't squander the extra time. Meanwhile, there are some organizations that are just opposed to ICD-10, period.

ICD-10 is complex and can't be explained in a nutshell. But the bottom line is that the transition from ICD-9 to ICD-10 diagnosis and inpatient procedure codes impacts nearly every system used by doctor practices and hospitals, from billing systems to medical records.

The first ICD-10 delay in the United States came in January 2009, when the Centers for Medicare and Medicaid Services (CMS) pushed the implementation date out two years, from the original compliance date of Oct. 1, 2011 to Oct. 1, 2013.

Most recently, on April 9, 2012, the U.S. Department of Health and Human Services (HHS) proposed extending by one year the deadline for ICD-10 compliance to Oct. 1, 2014 from Oct. 1, 2013.

When U.S. healthcare providers, payers, and other covered entities were told they had to comply by Oct. 1, 2013, many didn't expect they'd be ready in time, considering the many other regulation-related projects that they're also juggling. So, in February 2012, the Department of Health and Human Services (HHS) bowed to a chorus of opposition from health industry groups, including the American Medical Association, to push the Oct. 1, 2013 compliance deadline further out.

"A one year delay provides some breathing room, but a two-year delay would be a game changer," said Dr. Harry Greenspun, senior advisor for healthcare transformation and technology at Deloitte Center for Health Solutions. An extension longer than a year "penalizes people who are on track," he said.

Some suspected that CMS might abandon the move to ICD-10, or perhaps wait for the next revision--ICD-11--from the World Health Organization in 2015.

While industry watchers and insiders considered that slim possibility, that scenario seemed riddled with problems, too, even if laggards would've welcomed an indefinite pardon in tackling ICD-10.

For one thing, waiting for ICD-11 would eventually bring more work to healthcare organizations making the switch from ICD-9, since ICD-11 is expected to build on ICD-10. Also, a sudden about-face to skip ICD-10 and move to ICD-11 would be unfair and disruptive to organizations that have been diligent in transitioning to ICD-10.


ICD-10 includes 68,000 diagnosis codes, compared to 13,000 in ICD-9, while inpatient procedure codes in ICD-10 grow to 87,000 from only 11,000 in ICD-9. The new codes in ICD-10 provide greater clinical detail and cover medical treatments and technologies not reflected in the older ICD-9 codes.

CMS has said that while ICD-10 expands the number of codes, a large portion of ICD-10 codes only differ in one parameter. For example, nearly 25% of ICD-10 codes are the same except for indicating the right side of the patient's body versus the left. Another 25% of the codes differ only in the way they distinguish among "initial encounter," versus "subsequent encounter," versus "sequelae." Sequelae refers to conditions that are usually the aftermath of another disease, injury, or event, such as neck pain resulting from whiplash suffered in an auto accident.

Yet the increased code detail in ICD-10 means that required clinical documentation by providers "will change substantially." CMS says ICD-10 includes a more robust definition of severity, comorbidities, complications, sequelae, manifestations, causes, and a variety of other important parameters that characterize the patient's condition.

Even the American Medical Association, whose members have opposed ICD-10 because of the burdens and expense the conversion puts on doctor practices, acknowledges that the additional codes allowed by ICD-10 offer more flexibility than what's offered by ICD-9.

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A problem with ICD-9 is the lack of specificity in the information conveyed in the codes. For example, if a patient is seen for treatment of a sprained or strained ankle, there are only four possible ICD-9 diagnosis codes.

However, under ICD-10, those diagnosis codes for a sprained or strained ankle expand to 72, including multiple new codes that distinguish between right and left ankle, as well as codes indicating initial encounters, subsequent encounters, and sequelae encounters, according to Cognizant Technology, an IT services firm that provides ICD-10 remediation work for healthcare providers and payers.

This greater detail in diagnosis codes allows for richer analysis down the line. It also reduces the chance that payers, upon submission of claims, will request additional information from physicians about why a patient was seen multiple times for sprains.

Image credit: Image courtesy of Cognizant Technology.

Recommended Reading:

Don't Hit Snooze Button On ICD-10

Feds Propose One-Year ICD-10 Delay

AMA Wants To Put Brakes On ICD-10 Implementation

Stay On Course With ICD10 Plans, AHIMA Urges

ICD-10 Boosts Appeal Of Computer-Assisted Coding Tools

Health IT Priorities: Time To Deliver

Feds May Delay ICD-10 Deadline

IT Decisions Hang On Supreme Court Healthcare Ruling

If Court Squashes 'Obamacare,' IT May Suffer: HIMSS

Feds Release New Healthcare Quality Measures

Healthcare CIOs Need To Understand Physicians' Pain


The American Health Information Management Association has a long list of reasons why the organization supports ICD-10, said its CEO, Lynne Thomas Gordon. Among those reasons are the improved patient care and research capabilities that are promised by ICD-10.

For instance, ICD-10 will address many gaps in ICD-9's current diagnosis codes, and the expanded codes will allow for better analysis of healthcare data and provide more flexibility as new medical advances and discoveries evolve, said Gordon.

Today, medical technology and treatment advancements cannot be accurately reflected in current ICD-9 coding, including devices used in cardiac care, spinal fusions, and drug eluting stents. Limitations in coding often translate to limitations in coverage and reimbursement or confusion, said Gordon.

"The whole purpose of ICD-10 is to improve quality," she said.

Recommended Reading:

Don't Hit Snooze Button On ICD-10

Feds Propose One-Year ICD-10 Delay

AMA Wants To Put Brakes On ICD-10 Implementation

Stay On Course With ICD10 Plans, AHIMA Urges

ICD-10 Boosts Appeal Of Computer-Assisted Coding Tools

Health IT Priorities: Time To Deliver

Feds May Delay ICD-10 Deadline

IT Decisions Hang On Supreme Court Healthcare Ruling

If Court Squashes 'Obamacare,' IT May Suffer: HIMSS

Feds Release New Healthcare Quality Measures

Healthcare CIOs Need To Understand Physicians' Pain


The American Medical Association is one of the groups opposed to ICD-10. In letters to the HHS heads and Congress, the AMA has cited burdens that the ICD-10 transition puts on medical practices, especially as the code conversion work is taking place at a time when healthcare providers are faced with many other regulatory and health IT related mandates.

The AMA was among that groups that lobbied HHS to change its stance on ICD-10. Pictured above is the first page of a letter sent by AMA to HHS in February, citing the group's displeasure with ICD-10 and urging the agency to rethink its ICD-10 plans.

In part, it states: "In the wake of this onslaught of overlapping regulatory mandates and reporting requirements, HHS has an opportunity to ease the burdens on physician practices by halting the implementation of ICD-10 and calling on appropriate stakeholders, including physicians, hospitals, [and] payers to assess an appropriate replacement for ICD-9 within a reasonable timeframe."

While HHS is upholding the U.S. transition to ICD-10, the agency did propose in April to postpone the ICD-10 compliance deadline one year to Oct. 1, 2014.

Don't Hit Snooze Button On ICD-10

Feds Propose One-Year ICD-10 Delay

AMA Wants To Put Brakes On ICD-10 Implementation

Stay On Course With ICD10 Plans, AHIMA Urges

ICD-10 Boosts Appeal Of Computer-Assisted Coding Tools

Health IT Priorities: Time To Deliver

Feds May Delay ICD-10 Deadline

IT Decisions Hang On Supreme Court Healthcare Ruling

If Court Squashes 'Obamacare,' IT May Suffer: HIMSS

Feds Release New Healthcare Quality Measures

Healthcare CIOs Need To Understand Physicians' Pain


If you think moving from ICD-9 to ICD-10 is tough, the work would be even more burdensome for healthcare entities if the United States skipped ICD-10 and went straight to ICD-11.

That's because ICD-11 is expected to build on ICD-10. Plus, skipping ICD-10 midstream would be unfathomably unfair to those organizations that have already spent millions of dollars and many years converting their systems from ICD-9 to ICD-10.

The work that's already gone on with ICD-10 has been anything but quick and easy.

"We're not talking years, we're talking decades," said Carl Ascenzo, VP of global healthcare at Virtusa, a Westborough, Mass., IT services firm. "It's been 30 years since work started on ICD-10, and almost 20 years since the U.S. completed its version of ICD-10," said Ascenzo, pictured above. In fact, work on ICD-10 was started in 1983 by the World Health Organization and adopted by the World Health Assembly in 1992. In 1995, the United States finalized its draft of ICD-10, and compliance deadlines have been a moving target since.

Extending ICD-10 compliance to 2014 might help some organizations ensure that their clinical, billing, financial, and other systems are working properly for ICD-10, Ascenzo said. However, a delay longer than that would have been more disruptive to many organizations, he said.

"In my opinion, to do [the work] well, delay it a bit but don't stop it, we need to get this done," he said.

"Most companies take ICD-9 and put on a mapper for ICD-10 to make sure [diagnosis or procedure codes] match," he said. "The problem with that is the great expansion of codes in ICD-10, where before there might be four codes for a diagnosis, but now there might be 30 or 40," he said. "As we move forward with ICD-10, we have to make sure clinical accuracy is there as well as financial [accuracy]," in terms of codes used for reimbursement from payers, said Ascenzo, who was formerly CIO at Blue Cross Blue Shield of Massachusetts.

Also, while an ICD-11 draft by the World Health Organization is expected in 2015, it likely won't be ready for implementation for at least another five years after that--and the United States would also need to make modifications for its use here. That all would've meant even longer delays, said Ascenzo.

Recommended Reading:

Don't Hit Snooze Button On ICD-10

Feds Propose One-Year ICD-10 Delay

AMA Wants To Put Brakes On ICD-10 Implementation

Stay On Course With ICD10 Plans, AHIMA Urges

ICD-10 Boosts Appeal Of Computer-Assisted Coding Tools

Health IT Priorities: Time To Deliver

Feds May Delay ICD-10 Deadline

IT Decisions Hang On Supreme Court Healthcare Ruling

If Court Squashes 'Obamacare,' IT May Suffer: HIMSS

Feds Release New Healthcare Quality Measures

Healthcare CIOs Need To Understand Physicians' Pain


CMS has said that while ICD-10 expands the number of codes, a large portion of ICD-10 codes only differ in one parameter. For example, nearly 25% of ICD-10 codes are the same except for indicating the right side of the patient's body versus the left. Another 25% of the codes differ only in the way they distinguish among "initial encounter," versus "subsequent encounter," versus "sequelae."

Still, increased code detail contained in ICD-10 means that required clinical documentation by providers "will change substantially," according to CMS. ICD-10 includes a more robust definition of severity, comorbidities, complications, sequelae, manifestations, causes, and a variety of other important parameters that characterize the patient's condition, CMS said.

The move to ICD-10 doesn't impact just technology, but also an organization's business processes, people, and partners. The chart above (click here for a larger image), provided by IT services firm Cognizant Technology which performs ICD-10 remediation work, illustrates how the transition from ICD-9 to ICD-10 impacts payers and providers.

Image credit: Image courtesy of Cognizant Technology.

Recommended Reading:

Don't Hit Snooze Button On ICD-10

Feds Propose One-Year ICD-10 Delay

AMA Wants To Put Brakes On ICD-10 Implementation

Stay On Course With ICD10 Plans, AHIMA Urges

ICD-10 Boosts Appeal Of Computer-Assisted Coding Tools

Health IT Priorities: Time To Deliver

Feds May Delay ICD-10 Deadline

IT Decisions Hang On Supreme Court Healthcare Ruling

If Court Squashes 'Obamacare,' IT May Suffer: HIMSS

Feds Release New Healthcare Quality Measures

Healthcare CIOs Need To Understand Physicians' Pain

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