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Better codes, better patient safety.

The mandated switch to the new International Classification of Diseases version 10 (ICD-10-CM) is scheduled for 2013, and should signal a move to improved patient safety due to the greater detail of the new codes. While there are limitations within ICD-9-CM, there also are concerns surrounding the transition process for the new codes.

The shift from ICD-9-CM to ICD-10-CM will take the industry from 17,000 codes to almost 90,000 codes that can accommodate a host of new diagnoses and procedures. The 30-year-old ICD-9-CM codes have not been able to keep pace with advances in medical knowledge. Its utility, even for billing, is limited and the current codes do not provide a true reflection of a patient's condition.

Last year, the Centers for Medicare and Medicaid Services (CMS) issued a notice in the Federal Register replacing the ICD-9-CM code sets with expanded ICD-10 code sets, effective Oct. 1, 2011. A draft of ICD-10-CM has been produced; however, there is no anticipated implementation date for the codes. ICD-10-CM will include the addition of information relevant to ambulatory and managed care encounters, expanded injury codes, sixth and seventh characters, and combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition.


When hospitals view the migration as more than an upgrade in billing codes, they can prepare to utilize ICD-10-CM as a framework to redesign workflows as they relate to diagnosis and treatment protocols.

In addition to the improvements in claims processing and payment, the specificity of ICD-10-CM should help clinicians make better treatment decisions by enabling far more precise matching of a diagnosis to the appropriate code. The broadness of ICD-9-CM has often forced physicians and coders to select a billing code that comes closest to the condition being treated, but does not provide an accurate diagnosis. This can result in treatment delays while clinicians search for more detailed information, limiting the effectiveness of clinical decision-support (CDS) tools providing the best prompts and appropriate alerts, as well as reducing accuracy that limits the value of analytics designed to improve care.

The diagnosis coding language of ICD-10-CM, for example, should do a better job with elderly Medicare beneficiaries with chronic illnesses who often develop pressure ulcers. ICD-9-CM cannot capture the severity and location of these pressure ulcers as well as ICD-10-CM, which can identify the severity and location of the pressure ulcers under a single code, ensuring appropriate and timely treatment.

Significant Differences

For asthma cases, the terminology differs between ICD-9-CM and ICD-10-CM, with the new codes reflecting the current clinical classifications of asthma while ICD-9-CM does not. ICD-10-CM classifies asthma according to mild intermittent, mild persistent, moderate and severe. Recent asthma guidelines base diagnosis and treatment of asthma according to these categories. ICD-9-CM uses an alder classification of intrinsic and extrinsic asthma, which is no longer relevant for treatment.

Thus, if a clinician is using ICD-9-CM codes to analyze treatment outcomes, prevalence of asthma in the population and occurrences of acute episodes of asthma, she would not be examining the correct clinical categorization.

In addition, ICD-10-CM expands the diabetes mellitus codes to include the classification of the diabetes and the manifestation. ICD-10-CM also reflects the current clinical classification of diabetes, which is outdated in ICD-9-CM. There are many possible manifestations, including ophthalmic (retinopathy glaucoma, various levels of single or both eye impairment); neurological (carpal tunnel, nerve lesions, mononeuritis, polyneuropathy); circulatory disorders; and diabetes mellitus in pregnancy. ICD-10-CM includes combination codes for conditions and common symptoms or manifestations. A single code may be used to classify two diagnoses, a diagnosis with an associated sign or symptom, or a diagnosis with an associated complication.

Nurses not armed with this greater specificity are potentially in the dark when monitoring and following up on treatment regimens, potentially affecting patient safety. Frequent glucose monitoring, wound care, and the clinical needs of those with orthostatic hypotension, renal disease and retinopathy (all diabetes mellitus manifestations) can lead to increased nursing requirements. The number of potential diabetes mellitus manifestations in a single patient can result in errors in capture of the necessary codes with ICD-9-CM. These types of errors of omission can result in poor monitoring of patient conditions and adherence to treatment regimens.

Errors involving prescribed medications account for a significant percentage of total patient safety events reported by healthcare facilities. Medication errors and other causes of external injury are reported separately from the condition with ICD-9-CM. In ICD-10-CM, medication errors and external injury causes are embedded in the same code as the condition. This makes the new codes a more accurate way of reporting these adverse drug events to state and national databases. This, in turn, will allow healthcare organizations to benchmark, evaluate and identify opportunities for improvement.

Regardless of whether hospitals have electronic health records (EHR) or plan to implement them, the American Recovery and Reinvestment Act (ARRA) HITECH stimulus package incentives and fulfillment of the "meaningful use" clause will be directly affected by the ICD-10-CM implementation. When a clinician enters an ICD-10-CM code into an EHR, for example, the EHR's clinical decision-support module will automatically trigger any alerts for drug/drug interactions, treatment protocols and possible associated complications or condition notes.

Better Decision Support

The increased granularity of ICD-10-CM will enable more directed decision support for the patient. When patients suffer from multiple conditions or manifestations of a condition, any lack of clinical decision support that takes all of the factors into account can result in medical errors, lack of oversight or specific monitoring of manifestations, medication protocols and their effect on the patient during and after treatment. The ability to fully leverage clinical decision-support tools will help direct clinician monitoring to avoid complications or adverse drug events.

Capturing the exact patient diagnosis is where ICD-10-CM will have the greatest impact. Each health information technology system vendor (e.g., EHR, clinical information systems, billing) will bear the responsibility of updating its systems to accept the new ICD-10-CM codes. Simultaneously, hospitals will be evaluating how they can partner with vendors to change the work flow and clinical processes to positively impact patient safety with the adoption of ICD-10-CM.

Hospitals will be required to have an ICD-10-CM update clause included in their service contract, similar to the Y2K clause. This update clause should include a detailed training protocol--during and after the switch.

Not all healthcare systems will use the same EHR platform across the entire enterprise. These multisite, multiplatform enterprises will be required to synchronize the new codes enterprise-wide. They should ask vendors how they plan to help them accomplish this, which can adversely affect reporting, healthcare population trend tracking and the creation of accurate hospital treatment protocols.

When healthcare IT vendors update a hospital's systems, many will also incorporate the CMS/CDC general equivalence mappings (GEMs) to enable the hospital to have bidirectional reference ability between ICD-9-CM and ICD-10-CM. There will be patients whose original diagnosis was input to the system with ICD-9-CM codes and subsequent updated diagnosis happen after the switch to ICD-10-CM. In this scenario, the GEM reference database contained within the EHR still requires the clinician to manually search for the corresponding ICD-10-CM code that covers what may potentially be several ICD-9-CM codes charted under the original diagnosis before the code system update.

While the GEMs were developed as a road map to enable this mapping, using them manually will be labor intensive. Hospitals should ask their vendors to provide an automated way to accomplish this process. Vendors should also assure hospitals that any automated mapping process will accommodate future coding changes in ICD-10-CM, and eventually a move to ICD-11-CM.

Clinicians document patient care with many commonly used words. This "clinician friendly" free text is an ingrained aspect of clinician communication, regardless of whether they write diagnosis information into a chart for later EHR input or use a wireless tablet or other electronic notation device. Hospitals should ask vendors if they will provide a way to translate clinician free text and recognized medical terminologies into ICD-10-CM.

Also, translating the various clinical languages such as LOINC (logical observation identifiers names and codes) and SNOMED-CT (systematized nomenclature of medicine-clinical terms) into ICD-10-CM should also be addressed. Healthcare IT vendors should be ready to assist hospitals in finding ways to map these clinical terminologies to ICD-10-CM.

The Value to Clinicians

Emphasizing the patient safety value of the new ICD-10-CM codes to clinicians will help their buy-in and make for a smoother transition. The more specific the diagnosis, the easier identifying the best treatment and avoiding possible complications becomes. This will not only affect the individual patient but also patient populations locally, regionally and nationally. The new codes will facilitate faster and more detailed tracking and reporting of all patient populations served by hospitals and public health agencies.

The greater granularity of ICD-10-CM can also play a role in hospital infection control, such as an enhanced ability to track and identify MRSA (methicillin-resistant staphylococcus aureus) and other hospital-acquired infections.

The greater specificity of diagnostic information gathered from each patient encounter will allow hospitals to respond faster to potential community outbreaks by set ring aside resources such as vaccines and syringes, while strengthening staff decontamination and infection protocols to lessen the spread.

Public health agencies, in turn, will be able to more quickly analyze local and regional infection rate data for a more complete picture of a potential outbreak. Everything from salmonella and influenza to biological threats can be more quickly identified, contained and addressed with the more complete picture that ICD-10-CM will bring.

Mortality data from specific types of injuries can lead to identification of trends affecting speed limits, seat belt safety, crash barriers, building codes and construction techniques. ICD-10-CM can provide greater detail and tracking of all types of injuries, which allows modification of laws, public spaces and equipment that can make communities safer.

The United States is the only industrialized nation not using an ICD-10-based classification system for morbidity purposes. This makes sharing disease data internationally difficult, at a time when such sharing is critical for public health and the development of evidence-based medicine.

The World Health Organization requires member states to notify the organization of all events that constitute a public health emergency of international concern. They must also respond to requests for verification of information regarding such events. The concept behind this is that every country should be able to detect, rapidly verify and respond appropriately to epidemic-prone and emerging disease threats to minimize their impact on the health and economy of the world's population. ICD-10-CM will enable international comparisons of care quality and the sharing of best practices globally.

From the Catalog

According to The Health Language Engine (LE) provides an updating and modeling environment that enables users to update, map, search, browse, localize and extend content. This software uses APIs to connect to .NET, WebServices, JAVA and EJB environments. The database APIs operate with Oracle, SQL Server and Cache. The LE solution accelerates the incorporation of controlled medical vocabularies, coding standards, corresponding maps and other terminology-related content into healthcare IT applications. Additionally, LE enables this diverse content to be managed and delivered alongside local customizations and within their native structures. This speeds integration and reduces maintenance of both sets of content within existing systems.

For more information on Health Language solutions,

George T. Schwend is president and CEO of Denver, Colo.-based Health Language Inc.
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Title Annotation:Centers for Medicare and Medicaid Services; diagnosis coding
Author:Schwend, George T.
Publication:Health Management Technology
Article Type:Cover story
Geographic Code:1USA
Date:Jul 1, 2009
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