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Transitioning to ICD-10.

Gathering the History of Present illness

The story of your patient's visit begins with gathering the history of present illness (HPI) (i.e., the reason for the visit stated by the patient and in the patient's words). This process starts when the receptionist makes the appointment for the patient. The medical support staff is to gather information from the patient to assist the provider. This can include questions about the body part or organ system that is affected; whether this problem is constant, intermittent, or varied; how bothersome is it to the patient; how long has it been going on; whether the problem gets better, worse, or stays the same and under what circumstance; whether anything makes it better or worse; what else is happening at the same time; and whether the patient has any current chronic conditions that may be associated with the present visit.

HPIs on ICD10CMnic medical records are being thoroughly scrutinized; some providers are carrying forward the last encounter's HPI and not making any changes or updating information. This is a serious issue, and the Office of the Inspector General of the U.S. Department of Health and Human Services will be on the lookout. Be careful not to copy previous HPIs. Some portions of the previous HPI may be relevant to the current encounter, but when carrying forward, be sure to review and edit or modify to reflect the patient's condition today (for example, noting if the condition is better, worse, or the same--not changed or not getting worse). Providers will need to make a conscientious effort to review the HPI and make necessary changes; each encounter with the patient must appear as a unique visit. The record should clearly state the reason for the visit, pertinent history components, physician examination when appropriate, and the medical decision-making data involved, as well as the determined treatment plan.

On October 1, 2014, the United States will adopt the International Classification of Disease, Tenth Clinical Modification/Procedure Coding System (ICD10CM/PCS), 1 year later than we had initially reported in Urology Practice Management in September 2012. The reprieve, although welcome to many, is less than 17 months away, during which several phases of implementation must be completed. The timeline for implementing the code sets is divided into 4 phases: Phase 1: Impact Assessment, first quarter 2009 through second quarter 2012; Phase 2: Preparing for Implementation, first quarter 2012 through second quarter 2014; Phase 3: Go Live Preparation, first quarter 2013 through third quarter 2014; and Phase 4: Post Implementation, fourth quarter 2014 through fourth quarter 2015.

Phase 1: Impact Assessment

Your practice should already have completed the impact assessment. If you are behind schedule, you need to work hard now to catch up. The shift from International Classification of Diseases, Ninth Revision (ICD9) involves serious challenges, including transitioning from a system of 13,000 codes to a system of more than 68,000 codes in ICD10-CM.

You may recall that the implementation of a new generation of the 9 electronic standards for the Health Insurance Portability and Accountability Act (HIPAA), known as the American National Standards Institute (ANSI) Version 5010 (v5010), is a part of this process. ANSI v5010 replaced the electronic transaction standards ANSI v4010/ v4010A. Once ICD10CM goes into effect, any transactions that are not compliant with HIPAA (i.e., not using ANSI v5010) will be rejected. The new codes will be structurally different from the ICD9 codes (Table 1 and Table 2). By now, you should have a steering committee in place or have devised a communication schedule involving everyone in your practice who will play a role in implementing the new coding system. If you have not already done so, you should take the following steps as soon as possible:

* Begin operational processes

* Evaluate workflow (data and staff)

Identify how to improve workflow

* Conduct a gap analysis

* Modify your software and upgrade your hardware

* Educate your staff

Phase 2: Preparing For Implementation

Now is also the time for the staff to review the practice's current procedures and improve upon them, making them more efficient and cost-effective. The newly provided codes were designed to ensure that the collected data reflect patients' conditions more precisely, decrease claims rejections, and improve the benchmarking of data and public health records. Examine the systems, vendor contracts, and costs for both your electronic health records (EHRs) and practice management systems. Use the following questions as a guide through this process.

Are your contracts with payers ready for the move? You may need to review and update these contracts to pave the way for the move to ICD10.

Will your current practice management system accommodate the change, or will you require a new system? Choose a software package that will accommodate the necessary changes. Review the problems your practice has experienced in the past 2 years and how they affected your practice and cash flow. Ask yourself what responses and issues you faced with your current practice management software vendor/customer support. How difficult was it to resolve any problems? What did it cost you in time, lost productivity, staffing, and overtime to "catch up" from having your system down for maintenance and upgrades?

Will the upgrade to the new system involve a fee? If so, how much will that cost? Will your vendor(s) provide the codes at no cost?

What is your vendor(s') timeline for implementation, and when will they allow you to test your system? You will need to know when the upgrade to your existing system will be complete or the entirely new system will be available. When it is complete, you then need to know whether your vendor(s) will provide training for your practice, and if so, what the training will cost.

Have you begun to modify your templates? Remember to update your forms and superbills. The newer forms will, by necessity, be far more comprehensive and complex than the older forms.

Will your vendor(s) load your specialty specifically, or will all of the specialties be included in your system? Will diagnoses be searchable by partial terms, and will they include the coding guidelines, rules, and exceptions to the guidelines that your practice may encounter? For example, when coding for malignancies, the malignancy will remain the principal diagnosis when the treatment is directed at the malignancy. However, if a patient is admitted for anemia associated with the malignancy and the treatment is exclusively for anemia, the code for the malignancy will be listed as the principal or first-listed diagnosis, followed by the code D63.0, Anemia in neoplastic disease.

Next Steps

* Contract with a consulting service

* Redesign and reprint paper forms

* Convert your data

* Maintain a dual system until all of the problems with the new system have been worked out

* Purchase software, seek educational resources, and use mapping tools as needed to help with the transition

* Anticipate decreased coding accuracy and work to solve those associated issues

* Monitor coding from the point of implementation

* Develop a communications plan in preparation for going live

* Regularly update your senior executives

Phase 3: Go Live Preparation

Before you "go live," be sure that any systems that are not working properly are corrected. Again, make sure you know what your vendor(s) will be able to do to help you with the transition. If you do not know for sure, ask your vendor(s) whether a mapping program will be provided. General Equivalence Mappings (GEMs) were developed to help you with the conversion, because ICD-10 is more specific than ICD-9. (1)

GEMs are basically translation tools for not only payers and providers, but anyone working with coded data. Remember, the diagnostic codes have increased from 14,025 to 68,069. Procedural codes have increased from 3824 to 72,589. The GEMs can be used to convert your data from ICD-9 to ICD-IO-CM/PCS and back again (i.e., forward and backward mappings, also known as crosswalks).

The GEMs will allow you to translate data for tracking quality, recording morbidity and mortality, calculating reimbursement, or converting an ICD-9-CM-based application to ICD-10-CM/PCS. They also can be used to help your practice convert payment systems, payment and coverage edits, risk adjustment logic, quality measures, and research applications germane to trend data. In cases where there is no translation between an ICD 9-CM code and an ICD-10 code, a flag will indicate "No Map." One such example is ICD-9-CM Procedure Code 89.8--Autopsy, for which there is no translation in ICD-10-CM/PCS.

Next Steps:

* Confirm with your vendor(s) that the needed upgrades are in place

* Finalize all system changes from January through September 2014

* Complete testing

* Conduct claims testing

* Make any necessary modifications and reassign testing

* Have a contingency plan in place

Phase 4: Postimplementation

Reeducate your staff as necessary and continue to monitor all of your systems--cash flow, productivity, revenue, and coding accuracy. In ICD10CM, chapter 14 will provide the codes for diseases of the genitourinary system. These were provided in chapter 10 in ICD9CM. Some of the conditions that were moved from the Signs, Symptoms, and Ill-Defined Conditions chapter in ICD9CM also will be found in chapter 14. These include urge incontinence, incontinence without sensory awareness, male stress incontinence, overflow incontinence, and nocturnal enuresis. (2) Examples of ICD10CM/PCS urology codes are provided in Table 3 and Table 4.

The ICD10CM codes for erectile dysfunction provide an example of the higher level of specificity required. The ICD9 code for erectile dysfunction is 607.84. The new categories for erectile dysfunction include:

* N52.0 Vaculogenic erectile dysfunction with subcategories

* N52.01 Erectile dysfunction due to arterial insufficiency

* N52.02 Corporovenous occlusive erectile dysfunction

* N52.03 Combined arterial insufficiency and corporovenons occlusive erectile dysfunction

* N52.1 Erectile dysfunction due to diseases classified elsewhere (code first underlying disease)

* N52.2 Drug-induced erectile dysfunction

* N52.3 Postsurgical erectile dysfunction

* N52.31 Erectile dysfunction following radical prostatectomy

* N52.32 Erectile dysfunction following radical cystectomy

* N52.33 Erectile dysfunction following urethral surgery

* N52.34 Erectile dysfunction following simple urethral surgery

* N52.39 Other postsurgical erectile dysfunction

* N52.8 Other male erectile dysfunction

* N52.9 Male erectile dysfunction, unspecified

To further highlight the differences between ICD9 and ICD10 CM, there is yet another category for Other Male Sexual Dysfunction (N53), which includes several subcategories:

* N53.1 Ejaculatory dysfunction

* N53.11 Retarded ejaculation

* N53.12 Painful ejaculation

* N53.13 Anejaculatory orgasm

* N53.14 Retrograde ejaculation

* N53.19 Other ejaculatory dysfunction

* N53.8 Other male sexual dysfunction

* N53.9 Unspecified male sexual dysfunction

Exceptions to the Rule

As one would expect, there are several exceptions to the rule. One occurs in the etiology/manifestation convention regarding placement of the code, as well as the placement of the notes "use additional code" and "diseases classified elsewhere." Certain conditions have both an underlying etiology and multiple body system manifestations owing to the underlying etiology. For such conditions, the ICD9 coding convention requires that the underlying condition be sequenced first, followed by the systemic manifestation(s). Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes--etiology followed by manifestation. (3)

Another exception to the rule occurs with regard to syndromes. When coding syndromes, it is important to follow the alphabetical index guidance. When there is no index guidance, assign codes for the documented manifestations of the syndrome. (3)

Looking at the positive side of the ICD10CM/PCS transition, once we are prepared, trained, and on our way, the higher level of specificity with which this coding system will allow us to code will paint a very clear picture for the insurance carriers and will clearly identify patients' medical problems to justify the medical services performed. All of this assumes, of course, that the provider is well educated on this system and is utilizing it to its fullest potential. The level of detail required should result in decreased requests from insurance carriers for medical records which, in turn, will allow the staff to work on other tasks that are critical to the daily operations of your medical practice.

Next Steps:

* Monitor the impact of ICD10 on reimbursement

* Meet with your staff regularly to share information

* Monitor the functionality of your practice management and EHRs systems

* Monitor coding accuracy and productivity

* Train or retrain your staff as required

* Monitor your case mix

* Resolve payment issues

* Communicate with payers


A significant amount of concern and resistance remains in accepting ICD10CM/PCS. However, it is coming, and time is ticking away. It is better to take a look at things now, to take the first step and have the first meeting to see who in your organization knows anything about ICD10CM/PCS. Your first step may be to send someone to a seminar or assign someone to spend the time to research the basics online. Table 5 includes helpful websites that will provide education and training on ICD10.

To fully participate in this system, it is highly recommended that you fully understand the coding guidelines. Although some of the guidelines have been retained, there are exceptions--particularly with the new combination codes. Diabetes is a good example of a disease that requires combination codes. For example, type 2 diabetes mellitus with related chronic kidney disease requires a combination code (E11.22). The coder will be instructed to use an additional code to identify the stage of chronic kidney disease.

Remember, the ICD10CM codes will be used by all medical providers. The ICD10PCS codes are only for inpatient hospital procedures and are used only by the hospitals. You must provide a full description of a procedure or diagnosis. It would be a grave error to truncate these codes, as we are attempting to seek the highest level of specificity. If your vendors download only partial codes, the data will not serve its purpose.


(1.) General Equivalence Mappings. 10/downloads/GEMSCrosswalks BasicFAQ.pdf. Accessed April 17, 2013.

(2.) Contexo Media. Coding and Billing for Urology/Nephrology: A Comprehensive and Illustrative Specialty Guide. URO11_Sample.pdf. Accessed April 17, 2013.

(3.) American Medical Association. 4[R] 2013 Professional Edition. 2013; American Medical Association.

Susanne Talebian, CHBC, RMM, CMOM, CPC-I, CPC, CUA, CCS-P, PCS, is a Certified Healthcare Business Consultant, American Health Information Management Association--AHIMA Certified ICD-10-CM/PCS Trainer.

Note: This article is reprinted with permission from Urology Practice Management (May 2013, vol. 2, no. 1, pp. 1, 10, 12, 14-15).

Susanne A. Quallich, APRN, BC, NP-C, CUNP Urologic Nursing Editorial Board Member
Table 1.
Structural Differences between ICD-9-CM and ICD-10-CM
Diagnostic Codes

-ICD-9-CM                                       ICD-10-CM

3 to 5 digits                                 3 to 7 digits
Digit 1, numeric                             Digit 1, alpha
Digits 2 to 5, numeric                      Digit 2, numeric
                                     Digits 3 to 7, alpha or numeric

ICD-9-CM indicates International Classification of Diseases, Ninth
Revision,  Clinical Modification, ICD-10-CM International
Classification of Diseases, Tenth  Revision, Clinical Modification.

Table 2.

Structural Differences between ICD-9-CM and ICD-10-CM
Procedure Codes

ICD-9-CM                                        ICD-IO-CM

3 to 4 digits                                   7 digits
All digits, numeric                        Each digit, either
                                            alpha or numeric

ICD-9-CM indicates International Classification of Diseases, Ninth
Revision,  Clinical Modification, ICD-10-CM International
Classification of Diseases, Tenth  Revision, Clinical Modification.

Table 3.
Examples of ICD-10-CM Urology Codes

Enlarged prostate                N40.0
Enlarged prostate with LUTS      N40.1

Additional Codes for Associated Symptoms

Incomplete bladder emptying     R39.13
Nocturia                         R35.1
Straining on urination          R39.16
Urinary frequency                R35.0
Urinary hesitancy               R30.11
Urinary incontinence             N39.4
Urinary obstruction              N13.8
Urinary retention                R33.8
Urinary urgency                 R39.15
Weak urinary stream             R39.13

ICD-10-CM indicates International Classification of Diseases, Tenth
Revision, finical  Modification, TURP, transurethral resection of the
prostate; LUTS, lower urinary tract symptoms.

Table 4.
Examples of ICD-10-PCS Codes

Cystoscopy               OTJB8ZZ
TURP                     OVB08ZZ
Bladder suspension-      OTUB8JZ
Foley catheterization    OT9D70Z

ICD-10-CM indicates International Class-
ification of Diseases, Tenth Revision,
Clinical Modification; TURP, transurethral
resection of the prostate.

Table 5.
Websites to Help with the Transition to ICD-10


AAPC         ICD-9 to ICD-10 Crosswalk for Urology (

CMS          (
             covered Entities. pdf.)

Medscape     Transition to ICD-10. Getting Started
             Urology Practices

Other        Preparing Your Urology Practice for ICD-10

             ICD-1-0 Coding, Billing, Documentation Webinar
             ICD-9 to ICD-10 Mapping for Urology

             2011 ICD-9-CM to ICD-10-CM Diagnostic Code Mapper
             for Urology

AAPC indicates American Association of Professional Coders; AHIMA,
American  Health Information Management Association; CMS, Centers for
Medicare &  Medicaid Services; ICD10, International Classification of
Diseases, Tenth Revision.
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Title Annotation:General Clinical Practice
Author:Talebian, Susanne
Publication:Urologic Nursing
Geographic Code:1USA
Date:Jan 1, 2014
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