Abstract

Background:On 1 October 2015, a new federally mandated system goes into effect requiring the replacement of the International Classification of Disease-version 9-Clinical Modification (ICD-9-CM) with ICD-10-CM. These codes are required to be used for reimbursement and to substantiate medical necessity. ICD-10 is composite with as many as 141,000 codes, an increase of 712% when compared to ICD-9.

Methods:Execution of the ICD-10 system will require significant changes in the clinical administrative and hospital-based practices. Through the transition, diminished productivity and practice revenue can be anticipated, the impacts of which the spine surgeon can minimizeby appropriate education and planning.

Results:The advantages of the new system include increased clarity and more accurate definitions reflecting patient condition, information relevant to ambulatory and managed care encounters, expanded injury codes, laterality, specificity, precise data for safety and compliance reporting, data mining for research, and finally, enabling pay-for-performance programs. The disadvantages include the cost per physician, training administrative staff, revenue loss during the learning curve, confusion, the need to upgrade hardware along with software, and overall expense to the healthcare system.

Conclusions:With the deadline rapidly approaching, gaps in implementation result in delayed billing, delayed or diminished reimbursements, and absence of quality and outcomes data. It is thereby essential for spine surgeons to understand their role in transitioning to this new environment. Part I of this article discusses the background, coding changes, and costs as well as reviews the salient features of ICD-10 in spine surgery

Keywords: Diagnostic coding systems, ICD-10, implementation, practice management, spine surgery

INTRODUCTION

“It may be hard for an egg to turn into a bird: It would be a jolly sight harder for it to learn to fly while remaining an egg. We are like eggs at present. And you cannot go on indefinitely being just an ordinary, decent egg. We must be hatched or go bad” by C. S. Lewis

Coding has always been an essential method for physicians and hospitals to document disease and procedures in order to get reimbursed for the work done rather than a means to communicate the disease condition. Administrative assistants usually perform the tasks of coding and proper documentation and submission of health insurance claims. In some cases, there is a disconnect between the physician and coder, which in turn causes coding errors resulting in improper reimbursements and unreliable data for scientific or organizational analysis. The International Classification of Disease-version 9 (ICD-9) coding system that has been used in the US since the 70s has now become archaic, thus resulting in the Department of Health and Human Services (HHS) mandating a change to an advanced and increasingly granular International Classification of Disease-version 10- Clinical Modification/Procedure Coding System (ICD-10-CM/PCS).

The ICD-9 will be replaced by the ICD-10-CM/PCS; that will be the standard for coding diagnoses substantiating medical necessity and professional reimbursement. The change mandated by HHS is set to occur on 1 October 2015, following a delay of about a year. The implementation of ICD-10 will make it the Health Insurance Portability and Accountability Act (HIPAA)/Centers for Medicare and Medicaid Services (CMS) standard from that day forward, and use of the old codes for claims and transactions will result in denials of reimbursement. Although various countries have adopted and used the ICD-10 system over the past two decades, presently there are no other countries utilizing this unique ICD-10-CM/PCS coding system. It is a highly specific coding system that can be appropriately applied to a socio-economically advanced nation where a number of diseases have unending co- orbidities The World Health Organization (WHO) granted the US permission to develop this coding system, as it could most effectively utilize this coding system given its advanced technology.

MATERIALS AND METHODS (PRELIMINARY CONCEPTS AND LITERATURE REVIEW)

History and evolution of coding systems

The decision to code and classify disease began in the late 16^th century in London following the death of 81 people as the bill of mortality. This was subsequently followed by a number of classification schemes that finally evolved into the WHO taking responsibility for the International Classification of Disease (ICD) in 1948 and then having it evolve into the present ICD-10 with its various modifications[ 17 18 ] [ Table 1 , Appendices 1 and 2 ]. We evaluate relevant literature on the topic and summarize the key findings that are essential and relevant for the spinal surgical community.

Table 1

Timeline in the evolution of disease coding

Appendix 1

Medical and surgical section

Appendix 2

Medical and surgical section

US national center for health statistics

The US National Center for Health Statistics (NCHS) created an extension of the ICD-9 codes to include morbidity data codes.[ 12 13 ] The NCHS and CMS are the agencies in the US responsible for incorporating modifications to the ICD-9-CM. This was the coding system that was adopted to identify morbidity and mortality, classify disease, and utilize these codes for healthcare claims by hospitals, physicians, and associated healthcare providers and facilities. This system was used to evaluate payment for health services, utilization of services, healthcare trends, costs, research, and planning for the future of healthcare in the US.

Medicare catastrophic coverage act

The Medicare Catastrophic Coverage Act was passed by the US Congress in 1988, making ICD-9-CM codes the standard for processing Medicare claims. This resulted in commercial and third-party payers following Medicare's lead. They adopted the ICD-9-CM for diagnosis reporting in order to maintain medical necessity. As a result, the ICD-9 system has become the core classification to code for commercial and government insurance reimbursement.

Health insurance portability and accountability act

Subsequently, in 2003, HIPAA of 1996[ 1 ] designated the present ICD-9 system of codes that constitute the standard for reporting diagnoses and procedures in all electronic administrative transactions. The HHS followed this with a mandate requiring the change of ICD-9 codes to the new ICD-10 system on 1 October 2015. With this change, ICD-10-CM will be used for diagnostic codes and ICD-10-PCS for procedural coding; all HIPAA covered entities must make the change and also adopt electronic billing.[ 2 8 14 16 ]

10 Standard transactions (HIPAA)

There are 10 standard transactions that HIPAA[ 1 ] has identified for electronic exchange of data, payments, diagnoses, and encounters. In addition, there are other code types used to identify specific diagnoses and clinical procedures for claims and reimbursement. The lists of codes in Table 2 indicate the present mix used by physicians, hospitals, and administration to generate appropriate payments and reimbursement.

Table 2

Types of codes that are/will be used in the spine practice setting

Structure of ICD-10

A current codebook is available from the CMS website. This website includes references and guidelines as well. The link is http://www.cms.gov/ICD10.

The migration to ICD-10 requires a significant change in documentation and coding practices. This impacts physician documentation in the office and hospital setting.

Increased granularity and specificity of ICD-10-CM/PCS codes

The ICD-10-CM/PCS codes have an increased “granularity” or specificity.[ 7 ] In regards to clinical documentation for ICD-10-CM coding, spine surgeons will be required to provide detailed histories, examinations, surgical and procedural notes. These will have to include the duration of symptoms (e.g. acute or chronic) and directly document the laterality/location of the pathology (anatomical location) and visits (e.g. initial or subsequent). Better documentation should improve claim adjudication and reduce denials. Although most of this will be an automated process, in instances of an audit, appropriate documentation will make the query process substantially easier while enabling coders to clarify issues without having to query the provider multiple times for answers.

Seven characters for ICD-10-CM versus five for ICD-9-CM

The ICD-10-CM codes have a structure similar to that of ICD-9-CM, but have seven characters rather than five that are present in the ICD-9-CM. The first three values are for describing common traits, while the remaining four are for greater specificity. The ICD-10 has many more additions and code choices, more information for ambulatory and managed care settings, increased number of injury codes, combining diagnostic and symptom codes, and increased specificity in code assignment.

ICD-10-PCS codes directly relate to surgery

Of more interest to the spine surgeon, however, are the ICD-10-PCS codes which directly relate to surgery (e.g. the level or anatomical component, the approach, and equipment used/inserted). The ICD-10-PCS is multi-axial in that each of the seven characters is independent and retains its meaning throughout the range of codes whenever possible.[ 20 21 22 ]

Medical/surgical section

The medical/surgical section in this is fairly consistent [ Table 3 ]. The surgical note documentation has to very specifically correspond to each of the characters entered. The complexity of the procedures, types of devices/instrumentation used in the procedure, and approach make this all the more difficult for the coder to understand, and there may be a period where they will have to work with the surgeons to clarify and standardize notes to a significant amount, so as to enable quicker processing.

Table 3

Decoding the ICD-10-PCS

Deciphering the codes

The relationship between the procedure codes entered by the surgeon [current procedural terminology (CPT)] for professional services provided in the hospital setting, ultimately ties into the ICD-10-CM/PCS codes. The resulting assignments in Ambulatory Payment classification (APC)/Diagnosis Related Groups (DRGs)/ICD-10s are used for reimbursement to the hospitals and surgeons for the work performed by them [ Figure 1 ].

Figure 1

The claim processing sequence illustrates the process from initial placement of claims to the final assignments. Once professional and hospital services are documented, specific codes are entered that are combined with specific code sets on the ICD-10-CM/PCS system, which get assigned either an ICD-10 code for professional services in practice, an APC for the outpatient setting, or a DRG for an inpatient setting. Based on these final assignments, hospitals will get paid for services

The National Center for Health Sciences created a bidirectional system known as the General Equivalence Mappings (GEMs) to enable the old and new sets to communicate.[ 3 ] With the GEMs, it is possible to translate or map ICD-9 codes to the new ICD-10 code set, along with the ability to reverse match ICD-10 back to the ICD-9 code set, a process called reverse mapping. GEMs have a composite, intertwined, and non-reciprocal mapping structure where only 5% of the codes have a 1:1 relationship of ICD-9 with ICD-10 codes. As a result of a single ICD-9 code matching onto multiple ICD-10 codes and vice versa, the risks for inadvertent errors and the potential for abuse and fraud are present.[ 4 5 ]

DISCUSSION

Changing over to the new system will have a significant impact on practices and hospital systems. The transition will come with loss of productivity, revenue changes, and will require education for practitioners and coders. We have discussed the advantages and potential disadvantages of ICD-10. The potential advantages of the change to the new ICD-10-CM/PCS coding set will become evident anywhere between 5 and 10 years of implementation. Table 4 describes all the potential advantages that will be the result of this change. Keeping the probable advantages in mind, there are a number of skeptics that have rightly put forth the disadvantages they foresee and are described in Table 5 .

Table 4

Advantages of implementing ICD-10

Table 5

Disadvantages of implementing ICD-10

Impact on spine surgery

Cost to spine practices and hospital groups

The RAND Corporation had published their report in 2004, in which they analyzed the costs and benefits of the transition to ICD-10.[ 11 19 ] The analyses indicated benefits to society and the healthcare systems over a 10-year period, as this has been historically the time taken for transition and evaluating the benefits from prior transitions.[ 10 ] The RAND Corporation estimated benefits ranging from $100–$1200 million for new procedures, which may enable surgeons to perform procedures for patient necessity, to improve function and improve the patients quality of life. Many of these procedures are presently not performed because lack of reimbursements, and the addition of these new codes will significantly benefit the patients. The diminished ambiguity, particularly with ICD-10-PCS coding, being more logically organized and documented, will mean less fraudulent claims and rejected ones resulting in benefits of anywhere between $200 and 2500 million, although these benefits may accrue after more than 5 years of utilization. New procedures are coded accurately in ICD-10-PCS, thus avoiding confusion by clumping them with many codes from ICD-9 to define the procedure. This makes analysis of these procedures easier, making ineffective procedures redundant and those with improved outcomes more readily available to the patient population. This would essentially result in saving of approximately $100–$1500 million in the long run. A white paper authored by P. Zenner for Milliman and Robertson estimated a final saving of over $2.228 billion.[ 23 ] The estimated costs to health plans along, as projected by the American Health Insurance Plans (AHIP), the Health Trade Plan group, will be around $2-$3 billion.[ 12 ] Aetna has estimated costs of $50-$70 million a year through the 1^st year alone for the conversion.[ 15 ] The costs estimated to be incurred in 2008 by physician practices vary from approximately $83,000 for a 3-doctor practice with two administrative staff, $285,195 for a medium practice with 10 doctors and a professional coder with about six administrative staff, to about $2.8 million for a 100-physician practice with 10 coders and about 50 administrative staff. In a recent update of the report published by Nachimson et al., they have projected cost in 2014 to be 2-4 times the costs estimated in 2008, and this has been recently published on the American Medical Association website in detail (http://www.ama-assn.org/ama).

Productivity and training

The Canadian experience accrued from the ICD-10-CA transition between 2001 and 2005 has taught us interesting lessons.[ 6 9 ] There was a 52% loss of productivity immediately following the implementation of this new system. It took about 3-6 months after implementation to identify any significant improvements in the productivity and about a year to reach pre-implementation levels.[ 9 ]

Reimbursement

Inpatient DRGs for 26% of the claims, in the process of transition from ICD-9 to ICD-10, will not be affected; 74% of the DRGs will be affected as GEMs and reverse mappings have a number of confounding options. The resulting delay in payments may go on for a year from the implementation of these new code sets, thus indirectly affecting the physicians and surgeons practicing in the hospital. Additionally, delayed reimbursement could result in risks for small practice sustainability, with the absence of revenue effecting productivity and staffing.

CONCLUSIONS

The increasing pressures on the healthcare system make it necessary to control payments and costs for inappropriate services. New benchmarks and quality measures will be available, making obsolete procedures redundant. The accountable care model requires healthcare spending to be made for the right condition and corresponding appropriate service. The ability of surgeons to understand and adapt to the changes brought about by the ICD-10- PCS/CM's, that include the enhanced accuracy and detailing of spine procedures, details of devices inserted, clear delineation of surgical approach, laterality, and body part; will go a long way in making this transition easier. The ICD-10 implementation will enable accurate risk stratification, and increased data will provide appropriate allocation of resources to the population or disease.

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