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Health Policy Basics: Implementation of the International Classification of Disease, 10th RevisionImplementation of the ICD-10

Brian Outland, RHIT, CCS-P, CPC-O; Mary M. Newman, MD; and Margo J. William, MHA, CMPE
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 22 September 2015.


From the American College of Physicians, Washington, DC, and Park Medical Associates, Lutherville, Maryland.

Acknowledgment: The authors acknowledge the contributions of Kellyn Pearson and Shari Erickson.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1933.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Corresponding Author: Brian Outland, RHIT, CCS-P, CPC-O, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001; e-mail, boutland@acponline.org.

Current Author Addresses: Mr. Outland and Ms. William: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.

Dr. Newman: Park Medical Associates, 10755 Falls Road, Suite 200, Lutherville, MD 21093.

Author Contributions: Conception and design: M.M. Newman, B. Outland.

Drafting of the article: B. Outland.

Critical revision for important intellectual content: M.M. Newman, M.J. William.

Final approval of the article: M.M. Newman, B. Outland, M.J. William.

Administrative, technical, or logistic support: M.J. William.

Collection and assembly of data: B. Outland.


Ann Intern Med. 2015;163(7):554-556. doi:10.7326/M15-1933
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The International Classification of Diseases (ICD) standardizes diagnostic codes into meaningful criteria to enable the storage and retrieval of information regarding patient care. Whereas other countries have been using ICD, 10th Revision (ICD-10), for years, the United States will transition from ICD, Ninth Revision, Clinical Modification (ICD-9-CM), to ICD-10, on 1 October 2015. This transition is one of the largest and most technically challenging changes that the medical community has experienced in the past several decades. This article outlines the implications of moving to ICD-10 and recommends resources to facilitate the transition.

Figures

Grahic Jump Location
Figure.

Format of an ICD-10 code.

ICD-10 = International Classification of Disease, 10th Revision, Clinical Modification.

Grahic Jump Location

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ICD-10's challenge
Posted on September 22, 2015
James S Kennedy
President and Chief Medical Officer, CDIMD, Smyrna, TN
Conflict of Interest: President of CDIMD, a for-profit consulting firm engaging physicians and facilities in ICD-10-CM/PCS clinical documentation and coding integrity
Mr. Outland's summary of ICD-10-CM is factual and pertinent to its October 1, 2015 implementation.

Allow me to emphasize that ICD-10-CM coding, as with ICD-9-CM, is based ONLY on provider documentation in the medical record of ICD-10-CM's exact terminology, not on what is documented on a superbill, selected from an EHR's billing software, or what would make clinical sense based on my patient's circumstances. For example, the Coding Clinic for ICD-10-CM, 1st Quarter, 2014, page 6 does not allow me to select "systolic heart failure" as an ICD-10-CM code if all I have documented is "heart failure with reduced ejection fraction". Personal communications from the American Hospital Association's Central Office on ICD-10-CM prohibit me from assigning a code for diabetes with hyperglycemia if I document that my patient's diabetes is uncontrolled; I must say "out of control" or "poorly controlled". The term "urosepsis" no longer has a code; I must document either a urinary tract infection or sepsis due to UTI. Documentation of the systemic inflammatory response syndrome due to an infection can no longer be extrapolated to mean sepsis due to that infection. As in ICD-9-CM, coders are prohibited from assigning ICD-10-CM diagnosis codes from pathology reports unless I reaffirm these findings in my diagnostic statement. Obviously, compliant ICD-10-CM code assignment is not simply picking a code from the ICD-10-CM table or a list offered by my EHR.

I emphasize these points in that ICD-10-CM is a HIPAA transaction set whose submission governs payment of claims by the United States government and that code submission that is not based on provider documentation and strict adherence to ICD-10-CM coding conventions results in a false claim which, if inducing an overpayment, exposes the provider to severe penalties under the False Claims Act and the Civil Monetary Policies Act. Lack of provider knowledge and application of ICD-10-CM coding principles is not a valid defense. Sadly, the Coding Clinic for ICD-10-CM, the Cooperating Parties' official guidance to ICD-10-CM code assignment, is not available online or in most medical libraries; one must pay $1000/year for an electronic subscription or license specialized coding software with Coding Clinic as an add-on.

ICD-10-CM is also managed by four non-physician groups, the CDC, CMS, AHA, and AHIMA. I believe that a physician group should be a 5th Cooperating Party as to better align ICD-10-CM with the clinical language physicians read in Annals of Internal Medicine or other high impact literature and to offer official coding advice that's applicable to a physician's current vocabulary, not the government's administrative vocabulary.

Thank you.
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