The Conversion to ICD-10 to be Postponed for 1 Year

The conversion to ICD-10, which was earmarked for postponement by the Department of Health and Human Services (HHS) in an announcement in February, is now slated for a 1-year postponement. It was originally supposed to go into effect October 1, 2013 – this postponement will therefore give until October 1, 2014 to come into compliance.

In a document to be published in the Federal Register today, HHS cites the results of a survey conducted by the Centers for Medicare and Medicaid Services (CMS), showing that as many as 25% of providers (not only doctors, but also hospitals and insurance companies) will be unable to comply with the October 1, 2013 deadline.

What does this mean?
Those of us in U.S. health care have become accustomed to the ICD-9 coding system for  designating diseases (structured diagnosis), mainly used for billing. The ICD-9 system has been in effect since the 1970s.

Besides billing, the ICD-9 coding has been used for clinical research, clinical quality measures, and as structured diagnosis data in Stage-1-certified Electronic Health Records (EHR) systems. The impact of changing the underlying coding system used in all billing events in health care is substantial.

The ICD-10 coding system was developed in the 1990s, which means it is already 20 years old. The next level of coding, ICD-11, is waiting in the wings, and is broad enough to include genomic and genetic information, which were not part of previous systems (since such technology was not generally available at the time of their development). The ICD-10 code set has been used widely in many parts of the world, but not in the U.S. The codes look nothing like ICD-9 codes, and will therefore require a new learning curve for clinicians to become familiar with the new coding approach.

The biggest impact is that ICD-10 codes are much more specific, and contain over 76,000 codes (as opposed to the under-20,000 codes contained in ICD-9), which means that some of the more specific ICD-codes may have a one-to-one migration path to ICD-10, but many of the more general, non-specific ICD-9 codes often map to several ICD-10 options.

Stage 2 Meaningful Use
ICD-10 codes will need to be used in billing claims after the now-postponed deadline. However, the intent with Certified EHRs that are ready for Stage 2 Meaningful Use (beginning in 2014) is not to switch the Problem Lists from ICD-9 to ICD-10 – ICD-10 codes are merely an output of EHRs used for billing.

Instead, the Stage 2 vocabulary for designating Problem Lists (“structured diagnoses”) is to be SNOMED-CT (systematized nomenclature of medicine – clinical terms), which is a much richer hierarchical vocabulary containing several hundred thousand items. Of course, no one is expected to learn or memorize SNOMED codes – that is something in the background of automated systems, and can generate ICD-10 codes as a product in a more automated way.

As an example, the structured problem list may contain items that are easy to understand and clinically useful (e.g. “diabetes” and “diminished kidney function”), and the appropriate ICD-10 codes can be generated from this for the purpose of billing. There are already companies in existence, used by several EHR vendors, which allow easy search for clinical terms, and generate SNOMED codes, as well as ICD codes (ICD-9 and ICD-10)

Clinical Quality Measures will need to be re-worked in order to pull from SNOMED terms in the problem lists, rather than ICD-9 codes (as they currently often do). This will result in more accurate and informative measures. The Certification guidelines put out by NIST for Clinical Quality Measures already define the ICD-9 codes, ICD-10 codes, and SNOMED codes to be used in the numerators of each measure.

Conclusions
The delay in implementation of ICD-10 codes will mainly  have impact on billing systems, hospitals, and insurance companies. It is likely to be applauded by some in health care who see the conversion as excessively burdensome.

The impact on EHRs is less significant, as the change in nomenclature is moving from ICD-9 (a billing code-set) to SNOMED-CT (a clinical vocabulary). ICD-10 codes are a billing code-set that can be output from the EHR but mainly impact bills and not structured problem lists. The challenge for EHRs is to make the transition to SNOMED, and not just ICD-9 to ICD-10. Memorization of new codes is not something that health care will be asking clinicians to undertake – that is the burden of the technology clinicians are to be using.

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