Ready, set, go

ICD-10’s detailed requirements leave no room for procrastination

The conversion to ICD-10 will have a profound impact on medical practices, and few physicians are prepared, a CMO says.


For medical services delivered on or after Oct. 1, U.S. physicians must use the ICD-10 rather than the ICD-9 code set in reporting diagnoses on health insurance claims. ICD-10, which has nearly five times as many codes as ICD-9, requires much greater specificity in documenting patient visits and diagnosing conditions.

“Very few doctors are prepared for ICD-10,” says William W. Henning, DO, the chief medical officer for Inland Empire Health Plan in San Bernardino, Calif. At a recent meeting of the Osteopathic Physicians and Surgeons of California, Dr. Henning spoke with several DOs about the new code set. “When I asked if they were ready for ICD-10, they looked down and away and mumbled, ‘We don’t know what to do.’ And these are doctors who are well-connected and involved in organized medicine.”

The conversion to ICD-10 (which stands for International Statistical Classification of Diseases) will have a profound impact on medical practices. Electronic health record and practice management systems must be upgraded. And all physicians and other clinicians in a practice—as well as office management, coding and billing personnel—must become educated on the changes.

“The key to converting successfully to ICD-10 is not figuring out the right code. It’s having the right documentation in place so you can select the right code,” says health care technology consultant Stanley Nachimson, who writes the ICD-10 section of the AOA’s

This means that physicians may need to obtain more information from patients during the history and physical examination and order more tests, as well as take more meticulous notes. “You will have to document more,” Nachimson stresses. “In your SOAP notes, you will have to record more specific information.”

For example, when a patient has a fracture, the physician will need to document laterality, the specific bone broken, the place on the bone where the fracture occurred and the type of fracture. “You can’t just write down ‘broken arm,’ ” Nachimson says. “You will have to document the fracture classification.”

The new code set’s specificity for documenting sports injuries is particularly striking, according to Nachimson. While ICD-9 has one code for being struck by or striking against something without a subsequent fall, ICD-10 has two dozen codes. Code W21.01, for example, is “struck by football,” whereas W21.04 is “struck by golf ball,” W21.31 is “struck by shoe cleats,” and W21.4 is “striking against diving board.”

Physicians, thus, will need to ask patients additional questions to ascertain the causes of their sports injuries, Nachimson says.

The diabetes mellitus codes have also undergone considerable revision in ICD-10 and now include both the classification and the manifestation of the disease. Code E10.11, for instance, is “Type 1 diabetes mellitus with ketoacidosis with coma,” while E11.41 is “Type 2 diabetes mellitus with diabetic mononeuropathy.”

While it would be impossible for physicians to become familiar with all 68,000 codes in ICD-10, doctors should be well-versed with those that will be used most often in their practices, Nachimson says.

Dr. Henning, who practiced as a family physician for many years, points out that implementing ICD-10 will be much harder for primary care physicians, who “easily work with more than 200 diagnoses a day,” than it will be for subspecialists. “To be specific about all of those diagnoses will be very difficult,” he says.

Getting up to speed

Concerned that physicians are far behind in readying their practices for the new code set, Nachimson has developed a step-by-step implementation timeline for DOs.

By the end of this month, physicians need to determine their diagnosis patterns and become familiar with the codes they use most often in their practices. “It’s important that as a practice, you understand what conditions you generally work with, how to gather the information necessary to correctly code them and how to maintain the documentation to support them,” Nachimson says.

He recommends that no later than March, practices contact their health information technology vendors to make sure they are ready and able to upgrade billing and EHR systems for ICD-10.

Some practices’ contracts with vendors state that any health information technology upgrades to meet federal requirements will be done at no additional charge. Other practices will need to pay roughly $10,000 to $11,000 per physician to upgrade their EHR systems to ICD-10, according to Nachimson. Consequently, for larger practices, the costs of upgrading could be substantial.

In April, practices should contact the health insurance plans they contract with, Nachimson suggests. As health insurers retool their systems, practices and policies to comply with ICD-10, they will issue new rules for coverage and reimbursement. Physicians need to find out what such changes will mean for their practices.

Physicians should update their processes and software in May and test these changes internally in June, Nachimson says. “You’ll want to be sure you are correctly documenting and coding, that you can continue to collect necessary information and get it into your practice management and billing processes, and that you can produce accurate claims to be sent to the health plan,” he states on the AOA’s website.

In the final three months before the deadline, practices should conduct end-to-end testing. Using test data as close to real as possible, physicians need to go through all of the steps necessary to get paid by a health plan, Nachimson says. “Given the number of health plans and number of situations to be tested, this will be a time-consuming process,” he warns.

During the multistep implementation process, physicians can avail themselves of outside resources. Some county and state medical societies, specialty colleges and practice management organizations offer ICD-10 training classes. The Centers for Medicare and Medicaid Services provides a number of training tools on its website. In addition, independent ICD-10 consultants can help practices develop implementation plans.

Nachimson cautions against simply using tablet or smartphone apps that translate ICD-9 codes into ICD-10 language. “The translation apps are useful for an initial understanding of ICD-10 codes but are a very poor substitute for accurate documentation and direct selection of ICD-10 codes,” he says.

Dr. Henning would like to see an app developed that would generate ICD-10 code options when the physician enters a descriptive diagnosis. “Unlike a number of other apps, the purpose of this app would not be to crosswalk from ICD-9 codes,” he explains. “For example, a physician would be able to enter ‘diabetes with ketoacidosis,’ and the app would produce a number of E-code options from which the physician could select the code matching the patient’s current condition.”

No excuses

Physicians have had more than five years to get ready for ICD-10, notes Nachimson. The U.S. Department of Health and Human Services published the final rule requiring the conversion to ICD-10 in January 2009.

The original implementation deadline of Oct. 1, 2013, was postponed by a year because of challenges related to the economy and health system reform. But ICD-10’s debut is not likely to be postponed again, maintains Nachimson, who previously worked for CMS.

The reasons for upgrading the code set are many, he says. Developed in the 1980s, the terminology used in ICD-9 is outdated and doesn’t accurately reflect changes in practice and new clinical knowledge. In addition, ICD-9 codes lack the specificity needed today for quality measurement and improvement, clinical effectiveness research, public health tracking and biosurveillance.

Traditionally, U.S. physicians have not viewed diagnosis coding as a high priority because reimbursement has predominantly been based on Current Procedural Terminology (or CPT) codes, Nachimson observes. But as the country moves away from a fee-for-service payment system, the detailed ICD-10 diagnosis codes could have more influence on payment.

Regardless of the effect on reimbursement, physicians need to make ICD-10 conversion a priority. “The health care industry has had plenty of notice about the shift,” Nachimson says. “Physicians have to pay attention to that Oct. 1 deadline and do the work that they need to do before that date.

“Remember that improving documentation is critical to improving patient care. There is no time left for procrastinating.”


  1. Joe Morgan

    I had been putting off the ICD 10 saga for a while. Finally, after getting hundreds of emails from various sources which proposed to help me convert to the ICD 10 codes, I decided to see what I could do.

    First, most offers to help are simply organizational and schedules and not study programs.

    My thinking is if I want to learn I must actually see the books and do the coding.

    I searched the internet and found on You Tube a series of instructional videos on both the diagnosis section and the procedure section.

    To my surprise, when you go step by step and understand what each character in the codes means, it becomes much easier. After several examples you can do the coding yourself, which means anyone in your office can do it.

    But, the step by step instructions are the key to the process. If we want to treat a patient, we must first examine the patient – the code books – then we can look for specifics -and get the code we need.

    It’s all about getting the books, watching many videos and taking notes, and then doing it.
    My time was about 4 hours until I was able to sit at home and code.

    Specialist will only need an average of 25 diagnosis codes and similar number of procedure codes. You will soon be able to buy those or get them online free. It is the
    unknown code that you have to look up that is the problem.

    EMRs ought to offer the ICD 9 with the matching ICD 10, or choices which match, so doctors can get used to seeing the codes in place. Once we start seeing them and using them, they will be quickly adopted and become very routine.

    I suspect the procrastination factor for which doctors are famous is the great holdback.
    The dislike of change in a learned and practice routine/habit is the second holdback.

    Change the attitude, change the mindset to move forward, then do it!

  2. DrF

    Obviously an example if how we physicians have done an exemplary job of simplifying a system to decrease costs. Oh, no, that was Apple making us phones and computers that work.

    We choose instead to support a system which costs money and time in order for us to state what is easily stated in plain English and then insanely expect that complex system to help control costs and increase efficiency.

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