Will you be ready for ICD-10 conversion?

Better documentation will be vital

As the clock ticks down toward the implementation of ICD-10, case managers should start learning about the new coding requirements and how they are going to affect what they do on a daily basis.

The World Health Organization's International Classification of Diseases (ICD) 10th revision (ICD-10) has been used by other countries for many years, says Denise J. Hall, RN, an Atlanta-based partner with Pershing, Yoakley & Associates, a national healthcare consulting firm.

"The United States has been slow to covert because this is the only country where reimbursement is based on the ICD-9 codes. That all changes when every bill for patients discharged on or after Oct. 1, 2013, has to be billed with ICD-10 procedure and diagnosis codes," Hall says.

Otherwise, the claims for medical diagnoses and inpatient procedures might be rejected, and providers will have to resubmit them using the ICD-10 codes.

Hall recommends that hospitals begin training in 2012. While case managers do not need training on the specific codes, they do need to understand the level of documentation specificity required by the new coding process, especially if they're involved in clinical documentation improvement, Hall says. While ICD-9 uses five-digit numeric codes, ICD-10 is a seven-digit alpha-numeric coding system. The expanded fields make it possible to track much more detailed information about the patient's condition.

Because the coding for ICD-10 reflects a greater level of detail, coders will need more accurate and detailed information to assign the correct code to the procedure, says Michael Taylor, MD, vice president of operations at Executive Health Resources, a Newton Square, PA, healthcare consulting firm. (For more information on system upgrading for ICD-10, see story on p. 174) This change means that clinicians will have to provide more comprehensive documentation.

"Case managers need to be educated on the level of detail so they can educate physicians on the type of documentation necessary for the coders to do their job," Taylor adds.

When ICD-10 goes into effect, coders are going from a situation in which there are a limited number of codes to choose from, to one in which there are a tremendous number of options, Hall points out. ICD-9 has 14,000 codes for diagnoses and 3,800 procedure codes, compared to 68,000 codes for diagnoses possibilities and almost 73,000 procedure codes in ICD-10. For example, in ICD-9, there are 10 codes for diabetes. ICD-10 has 318 codes for diabetes.

"Every digit in the ICD-10 code means something, and they're all related to something else," Hall says. For example, today, codes for a fracture of a femur specify whether it's an open or closed fracture. "In ICD-10, that explodes into a laundry list of items like right or left leg, delayed healing, subsequent versus initial encounters," Hall says. "It's all very specific, and the documentation has to be complete so the coders can assign the right code."

The silver lining to ICD-10 implementation is that the detailed documentation required for coding is likely to help hospitals avoid denials from the recovery audit contractors (RACs) and other auditors, Taylor says. "The type of documentation needed for ICD-10 fits very well into the type of documentation we've seen work best to defend medical necessity," he says. "The level of detail in documentation needed to enable billers and coders to do their job appropriately using ICD-10 is the same level of detail that hospitals need to defend the claim if medical necessity is questioned."

Hall adds, "The shift to ICD-10 represents a lot of opportunities for hospitals right now if they begin to work on shoring up their documentation. If hospitals begin to work on improving documentation and making it as specific as possible, they may be able to see results almost immediately in the reduction of denials."

Every department involved

Hospitals need to be aware that ICD-10 touches almost every department: not just coding, information technology, and case management, but also patient access, revenue cycle management, social work, and ancillary services, Hall says. She advises case management directors to start to determine what ICD-10 will mean to their department and what changes they must make to make the transition to ICD-10.

Current hospital information technology is designed to store a five-digit field for coding, while ICD-10 uses a seven-digit field, says Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta. "ICD-9 codes are used in all the reports that case management directors use every day, such as quality indicators and core measures compliance," Malcolm says. "Case management software has to be updated to accept the expanded fields and to interface with all of the other information technology that uses ICD-10 codes."

In addition, keep in mind that insurance companies are going to need ICD-10 information to approve hospital stays and services, as well as post-acute services, she adds.

Hall suggests assessing and mapping the data flow process that now uses ICD-9 to establish where ICD-9 coded data is stored, captured, and transmitted throughout the patient stay. Determine what you will need to make the transition, including technology, staffing, and training.

Taylor adds that physician documentation is going to be a key factor in a successful ICD-10 conversion. It's not too early to start educating the physicians on the general principals of ICD-10, he says. "They need to know that their documentation needs to be more specific because the codes are more specific," Taylor says.


  • Denise J. Hall, RN, Partner at Pershing, Yoakley & Associates. Atlanta. E-mail: dhall@pyapc.com.