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Back to Table of Contents | April 2011

Clinical and Health Affairs

What You Can Do Now to Prepare for ICD-10

By Patrice Kuppe

■ The United States is moving toward adoption of the 10th version of the World Health Organization’s International Classification of Diseases (ICD) codes. Because the change will have a significant impact on electronic health record and billing systems, ICD-10 is being rolled out in phases over the next couple of years. Physicians will need to begin using the new diagnosis codes starting in October 2013. This article describes the differences between ICD-9 and ICD-10 and the steps physicians and clinics can take now to prepare for the implementation.

Big changes are underway in the realm of medical coding. Thanks to a mandate under the Health Insurance Portability and Accountability Act, hospitals, clinics, and health plans throughout the country are in the process of preparing for the implementation of the new International Classification of Diseases (ICD) 10 diagnosis and procedural codes for medical documentation and billing. The United States is one of the last countries in the world to adopt the 10th version of the codes, which was endorsed by the World Health Organization in 1990.

Because the change will have an enormous impact on electronic health record (EHR) and billing systems and the people who use them, it will take place in phases over the next several years. Billing and information technology personnel are already working to meet a January 1, 2012, deadline for upgrading systems to meet new standards for electronic claims and other revenue cycle transactions. But for most physicians, October 1, 2013, is the deadline to pay attention to, as that is when they will have to begin using ICD-10-CM, the new diagnosis codes. (Physician services will continue to be coded using Current Procedural Terminology [CPT] codes.) By this same date, in addition to the ICD-10-CM codes, hospitals must start using ICD-10-PCS codes to report the resources and procedures used in inpatient cases (Table 1). There will be no grace period for implementation.

The ICD-10 code set replaces ICD-9, which was adopted by the World Health Organization in 1975, the year Microsoft was founded and eight years before the virus that causes AIDS was identified. Obviously, much has changed with regard to computing and medicine since then.

Not only does ICD-9 no longer accurately describe the practice of medicine, it is inadequate for meeting the demands of medical record-keeping in the 21st century, which include tracking quality measures, monitoring potential public health risks, and submitting utilization data. In some cases, ICD-9 simply has no code for a condition. For example, it initially had no code for severe acute respiratory syndrome (SARS); a special update had to be made in 2003 to add codes for SARS. In other cases, terminology is outdated and inconsistent with current

Questions to Ask Your EHR and Billing System Vendors

  1. How will their application, business processes, or systems address your needs during implemention of ICD-10? Will they maintain tables for each code set? How long will ICD-9 be available for use? Some will propose an embedded or proprietary solution, while others will delegate the responsibility to the user organization.
  2. What is the migration strategy for making the change to ICD-10? Will multiple upgrades be required? This may be a concern for organizations that are not using the latest release of a vendor-supported application.
  3. Will they ensure you have the right tools in place to help you select the more specific diagnosis codes? Will they provide specific provider templates for each specialty?
medical practice. Asthma is one example where ICD-10-CM is much more precise and accurate than ICD-9-CM. With ICD-10-CM, asthma is classified as mild intermittent, mild persistent, moderate, or severe. Current guidelines base diagnosis and treatment of asthma according to these categories. But ICD-9-CM classifies asthma as intrinsic and extrinsic, which is no longer relevant for treatment. Thus, using ICD-9-CM codes to analyze treatment outcomes, prevalence of asthma in their patient population, and occurrences of acute episodes of asthma would not yield good data. ICD-9 has simply outlasted its usefulness.

ICD-10-CM versus ICD-9-CM

Physicians need to understand that the ICD-10-CM system is significantly different than the ICD-9-CM system. First, the number of codes will increase dramatically—from about 13,000 to 68,000. Second, the codes themselves are very different. The ICD-9-CM codes are only three to five characters long. The ICD-10-CM codes will be three to seven characters. In ICD-10-CM, the first character is alpha; characters 2 and 3 are numeric; characters 4 through 7 are alpha or numeric (Table 2).

The increased number of codes and the change in code length, combined with considerably more code granularity, allows for much greater specificity. For example, under ICD-9-CM, there is one code for a patient with a traumatic closed fracture of the shaft of the radius and ulna (813.23). Under ICD-10-CM, there are multiple possibilities, as the fourth character of the code will identify the type of fracture (eg, greenstick or transverse), the fifth and sixth characters the location and condition (right or left side and in some cases whether the fracture was considered displaced or nondisplaced), and the final character if the encounter was initial, subsequent, or sequela. The resulting code might look like this: A52.131A—indicating displaced fracture of neck of right radius, initial encounter for closed fracture.

Implementing the Change

Given these differences, all provider organizations and health plans will need to engage in significant planning to make EHR and billing system modifications or upgrades. They also will need to provide training and ongoing support to staff.

The key for successful migration to ICD-10 is to establish an environment in which new and old technology, along with like and unlike data sets, can co-exist and where information exchange can occur while the re-engineering of existing workflow and software takes place. Each provider organization will need to review all of its processes, systems, and reports and document where ICD-9 codes are currently used. In addition, each organization should conduct a financial impact analysis to determine if the new levels of specificity will change the reimbursements they receive from the government or commercial health plans.

To navigate the challenges, the Center for Medicare and Medicaid Services is developing general equivalence mapping (GEM) tools to convert data from ICD-9-CM to ICD-10-CM and vice versa.1 The GEMs will be like dictionaries that will enable users to translate from one code set to the other. The mapping tools can be used to help you calculate reimbursement, format new provider-specific prompts, and update reports or forms. But the GEMs should be used with care for a number of reasons:

  • There are new concepts in ICD- 10-CM that are not present in ICD-9-CM;
  • In a few cases, the GEMs may have no matching codes;
  • There may be multiple ICD-9-CM codes for a single ICD-10-CM code; and
  • There may be multiple ICD-10-CM codes for a single ICD-9-CM code.

Although these tools will aid during the transition period, organizations will still need to work with their EHR and


Centers for Medicare and Medicaid Services ICD-10 Overview

World Health Organization ICD-10 Training Tool

billing-system vendors to ensure that the transition goes smoothly (see “Questions to Ask Your EHR and Billing System Vendors”). They will have to decide how long they will keep ICD-9 codes since the codes are attached to the date of service and not to the date the record or claim was created. And those organizations that do not use EHRs will need to update their charge sheets and make sure their billing system is ready. Finally, no tool will be a substitute for learning the ICD-10 codes. Thus, all health care providers, coders, and support and billing staff will need to be trained.

Start Preparing Now

Clearly, organizations should be getting ready for this change. A number of steps should be taken well before October 1, 2013:

  1. Create a project team. Assign an executive to spearhead the work and to create awareness of the coming changes among both clinical and financial staff.
  2. Conduct an assessment. List the places where codes are used and stored.
  3. Talk to your software vendors about what the change could mean in terms of your systems. Successful conversion to ICD-10 will depend heavily on when your vendor has the upgrades completed and when they can be installed in your system.
  4. Identify the changes that you need to make in your practice to convert to the ICD-10 code set. For example, your diagnosis coding tools, “super bills,” and public health reporting tools will need to be updated, and you will need to make it clear which code list to use based on the date of service.
  5. Identify staff training needs and complete the necessary training.
  6. Conduct internal testing to make sure you can generate transactions with the ICD-10 codes.
  7. Conduct external testing with your clearinghouses and payers to make sure you can send and receive transactions with the ICD-10 codes.
  8. Conduct a financial assessment. The transition from ICD-9 to ICD-10 presents health care providers with a number of financial opportunities and risks, both during the transition period and over the long term. You should identify how the change could affect your organization in terms of financial performance, availability of working capital, and financial reporting.

We’ve handled changes in coding before. After an initial outcry over the conversion to the “new” CPT E/M code system in the early 1990s, we all adapted. In the end, the transition went relatively smoothly for those who took the time to plan and prepare. The move to ICD-10-CM will also be smooth if we start preparing now. MM

Patrice Kuppe is director of administrative simplification for Allina Health System.
1. Centers for Medicare and Medicaid Services. ICD-10 Provider Resources. Available at: Accessed: March 9, 2011.


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