- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Cannaday 2E, USA
- Department of Finance, Division of Revenue integrity, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905, USA
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL 32224, USA
- St. Vincent's Brain and Spine institute, Jacksonville, FL, USA
Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Cannaday 2E, USA
DOI:10.4103/2152-7806.137181Copyright: © 2014 Rahmathulla G. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Rahmathulla G, Deen HG, Dokken JA, Pirris SM, Pichelmann MA, Nottmeier EW, Reimer R, Wharen RE. Migration to the ICD-10 coding system: A primer for spine surgeons (Part 1). Surg Neurol Int 19-Jul-2014;5:
How to cite this URL: Rahmathulla G, Deen HG, Dokken JA, Pirris SM, Pichelmann MA, Nottmeier EW, Reimer R, Wharen RE. Migration to the ICD-10 coding system: A primer for spine surgeons (Part 1). Surg Neurol Int 19-Jul-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/migration-to-the-icd-10-coding-system-a-primer-for-spine-surgeons-part-1/
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
“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.
History and evolution of coding systems
The decision to code and classify disease began in the late 16th 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[
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.[
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[
10 Standard transactions (HIPAA)
There are 10 standard transactions that HIPAA[
Structure of ICD-10
A current codebook is available from the CMS website. This website includes references and guidelines as well. The link is
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.[
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.[
The medical/surgical section in this is fairly consistent [
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 [
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.[
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.
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.[
Productivity and training
The Canadian experience accrued from the ICD-10-CA transition between 2001 and 2005 has taught us interesting lessons.[
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.
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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