By Nina Youngstrom, Managing Editor,
Payment errors should be reduced significantly under ICD-10 diagnosis and procedure codes, which must be implemented by Oct. 1, 2013. Experts say that improvements over ICD-9 — including less ambiguity, more specificity, and standardized terminology and combination codes— will help hospitals improve their compliance. But at the same time, fraud investigators may also benefit from ICD-10 when it’s deployed with electronic anti-fraud tools.
“This is a boon for compliance,” said Rita Scichilone, director of practice leadership at the American Health Information Management Assn. (AHIMA). With 35% of overpayments identified during the recovery audit contractor (RAC) pilot related to coding errors, the new system could have a huge ripple effect, Scichilone said at a June 9 audio conference sponsored by the Health Care Compliance Assn.
The effective date of ICD-10 — which includes ICD-10-CM diagnosis codes for all settings and ICD-10-PCS procedure codes for hospital inpatients — can’t come soon enough, said Sue Bowman, director of coding policy and compliance at AHIMA, who also spoke at the audio conference. ICD-9 is running out of space for codes, its terminology is obsolete and it’s unable to keep up with advances in technology, she said.
According to Bowman and Scichilone, the many benefits of ICD-10 include:
- Preventing and detecting health fraud and abuse;
- Measuring quality and effectiveness;
- Monitoring resource use; and
- Improving clinical, financial and administrative performance and systems for payment and claims processing.
“This mandate affects all facets of health care and provides the greatest opportunity for a new compliance environment,” Bowman says.
To ensure ICD-10 can accommodate the current, more complex needs of the contemporary and future health care environments, its codes have three to seven alphanumeric characters, in place of ICD-9’s three to five, according to Bowman. But the transition to ICD-10 won’t spell an end to CPT and HCPCS codes, which will still be necessary.
Bowman described four ways that hospitals should be able to improve their coding selections with ICD-10, which means more accurate claims submissions and fewer claims denials:
(1) ICD-10 eases the reimbursement and compliance problems of combination codes. When patients now present at the hospital, the physician has to determine the chief complaint that occasioned the admission (known as the principal diagnosis), and the coder codes accordingly. The principal diagnosis drives the MS-DRG assignment. But it’s often unclear which of multiple conditions is principal and which should be coded as secondary diagnoses; there is often temptation to select the condition that will group to the highest-paying DRG, which is a compliance hazard.
Combination codes are used in ICD-10-CM to represent multiple conditions in a single code, whereas ICD-9-CM would provide separate codes for each condition, Bowman says. “It eliminates the need to wrestle with sequencing,” which is the term for putting codes in order of importance (i.e., principal, secondary), Bowman says. With combination codes under ICD-10, “there’s no judgment call on what is the principal diagnosis.” Suppose the patient has angina, artherosclotic heart disease and surgery for a heart condition. At present, both conditions would be treated and it would normally be a struggle to figure out which is the principal diagnosis that occasioned the admission. But with ICD-10, artherosclotic heart disease with angina is a single code.
(2) ICD-10-CM provides clearer instructional notes than ICD-9-CM, thereby improving coding accuracy. For example, standard definitions have been added for two types of “excludes notes,” she says. A note under a code that is identified as Excludes 1 means the code being excluded should never appear with the code it is excluded from. “A note identified as Excludes 2 means that the excluded condition is not part of the condition represented by the code where the note appears, but it is acceptable to report both codes together if the patient happens to have both conditions,” Bowman says. In contrast, ICD-9-CM doesn’t distinguish different types of excludes notes, so it’s often hard to determine how the note should be interpreted, which can lead to coding errors.
(3) ICD-9 is vague and nonspecific compared to ICD-10, according to Bowman, leaving too much room for error in describing what procedures were performed. ICD-10 codes are much more specific. For example, ICD-9 was implemented in 1979, when a scalpel was the only way to perform surgery. ICD-10 codes are written to reflect whether the procedure required a scalpel, needle or scope. Because the code itself tells the story, there is little room for error, Bowman says.
(4) Because ICD-10-CM diagnosis codes contain so much detail, there should be less room for queries, which are the forms hospital coders use to get clarification and additional information from physicians (usually when coding MS-DRGs). The fewer queries used, the less chance a mistake will be made when translating physician documentation into a DRG assignment.
ICD-10 to Help the Feds and Coders Alike
The government also will become more powerful in its anti-fraud efforts. In a new report, the Office of the National Coordinator for Health Information Technology (ONCHIT) says that shifting to ICD-10, which is essential to adoption of electronic medical records, will help promote the use of information technology that has become a core part of health fraud “management programs.”
ICD-10 also allows coders to be more productive without sacrificing integrity and accuracy. Consider the different approaches to coding the same procedure:
- ICD-10-PCD code 0270346 is dilation of coronary artery, one site, bifurcation, with drug-eluting intraluminal device, percutaneous approach.
- To arrive at the same procedure using ICD-9-CM takes five codes: 00.66 (percutaneous transluminal coronary angioplasty or coronary atherectomy); 00.40 (procedure on single vessel); 00.45 (insertion of one vascular stent); 36.07 (insertion of drug-eluting coronary artery stent (2); and 00.44 (procedure on vessel bifurcation).
Bowman also dispelled two myths about ICD-10:
(1) It’s a myth that ICD-10 implementation can wait until electronic medical records (EMRs) are in place. “Everyone is focused on electronic medical records and health reform and they [think they] don’t have time for ICD-10. The message we are trying to convey is that ICD-10 is not a separate project. It is part of these other projects,” Bowman says. “You won’t have better data coming out of EMR if you’re still using ICD-9.” The longer the wait, the higher the price tag. It’s more expensive to implement a new coding system in an EMR system because of the need for systems and application upgrades, she says.
(2) Another myth is that ICD-10 demands more medical-record documentation. On the contrary, Bowman says. Though specificity is a hallmark of ICD-10, it still has unspecified codes available when documentation doesn’t support a more specific code.
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