During my fellowship I did some urgent care moonlighting. Sometimes when things got slow we would turn to the International Classification of Diseases, Ninth Revision (ICD-9) coding book for entertainment. It was a bit frightening to see how many codes there were for injury from a nuclear weapon—16, to be exact. My favorite code, though, was E844, “sucked into a jet (aircraft).” I've always wondered what exactly that means.
Today if I spend time with ICD-9, it is as likely as not to look at lymphoma codes. ICD-9 was developed by the World Health Organization (WHO) over 30 years ago. Back then, lymphoma nomenclature was based on the Rappaport classification first proposed in 1956 and then modified in 1965. Since then we have been through the Working Formula, Revised European-American Lymphoma (REAL), and WHO classification schemes. No oncologist or hematologist trained since 1982 has used the Rappaport nomenclature, but ICD-9 does, and every so often I have to go back to the time when reticulosarcomas roamed the neoplastic landscape.
Granted, updates have been made from time to time, and now there are codes to distinguish marginal zone and mantle cell lymphoma, but there is only room for 2 groupings of 10 each in ICD-9 code, and the WHO classification defines 80 lymphomas in 4 broad groupings. Simply put, when it comes to lymphoma, we are overdue for ICD-10.
A Little ICD-10 History
ICD-10 was endorsed by the World Health Assembly in 1990. It consists of two sets of codes: procedural codes for hospital inpatient use (ICD-10-PCS) and diagnostic codes (ICD-10, Clinical Modification, or ICD-10-CM). ICD-10 was adopted by the WHO in 1993, and the developed world followed suit… with one exception. It has been 17 years since the United Kingdom adopted ICD-10. Canada, a slow adopter, began using it 11 years ago.
The United States has been the lone holdout for a long time, although our resistance has not been complete; our tumor registries have been using ICD-10 topography codes for 20 years. However, with the passage of the Health Insurance Portability and Accountability Act (HIPAA) of 2009, the Centers for Medicare and Medicaid Services (CMS) were ordered to make the switch. Initially set for October 1, 2011, implementation has been delayed twice, most recently on February 16, 2012. The newest line in the sand is October 1, 2014, and the Department of Health and Human Services (HHS) says that they really mean it this time.
Switching from ICD-9 to ICD-10 has its dedicated proponents and vociferous opponents. Among the former are those who envision ICD-10 as the ticket to the promised land of a 21st century healthcare system in which higher quality can cost less (the “less is more” argument is a topic for another day), and among the opponents are some who see a government plot that is good only for payers and Medicare Recovery Audit Contractors at the expense of patients and physicians. The truth is somewhere in between.
ICD-10: First, the Good News
There are many reasons to want something better than ICD-9, and ICD-10 has significant advantages over ICD-9. Whether “better” is actually “good” is a point of contention. It has been suggested that we should cobble ICD-9 together at this point and wait for ICD-11. Unfortunately, ICD-11 is at least another decade away. Medicine is moving too fast to wait that long. Here are the relatively good things about ICD-10.
First there is that thing about ICD-9 being full. It is a three- to five-character system. The first character is numeric or alpha, and the rest are numeric. A decimal point is placed after the third character. In the world of oncology, “neoplasia” is assigned codes 140 through 239. “Malignant hematology” gets 200 through 208, and “lymphoma” is allotted three of these. One is for “Hodgkin's disease” and the other two are for “non-Hodgkin's lymphoma,” although the actual term “non-Hodgkin's” is glaringly absent. The fourth character, the first after the decimal point, refers to the subtype of non-Hodgkin's lymphoma. Since we employ a base-10 counting system and the fifth character (always a digit) indicates the stage or site of disease, this leaves room for only 20 of the 80 subtypes of non-Hodgkin's lymphoma. There are many such examples of ICD-9 bursting at the seams.
ICD-10 has seven characters, with a decimal point after the first three. The first character is alpha, the second and third are numeric, and the other four can be alpha or numeric (with room for future expansion). The fact that there are 26 letters gives this system a whole lot more room before the decimal point, and the doubling of the number of characters following the decimal point gives it tremendous capacity for subtyping and descriptors, enabling it to accommodate both vertical and lateral growth of the diagnostic code.
Many consider this capacity for lateral growth to be critical as we move into the world of healthcare reform. Accountable care organizations cannot be accountable without the ability to measure the care that they are providing. For example, not only will all the lymphomas and their stages fit into ICD-10, but so will information about the context of the patient's encounter with the physician, such that the codes can distinguish between a new diagnosis, an ongoing problem, or a survivorship visit. It is argued that the lateral growth of the coding system will also greatly improve our ability to track public health and to conduct research, particularly in the health services arena.
I'm not entirely sure that this belongs under good things, but it can be argued that the timing has never been better to convert to ICD-10. Medicine is rapidly, albeit belatedly, moving to computerization. By now we have all met the January 1, 2012 deadline for converting our billing software to Version 5010, which is necessary to support ICD-10 on the billing end of things. On the front end, paper charts and ICD-10 would be a disaster, but with computerized documentation, the level of detail necessary to allow for ICD-10 coding can be prompted within the physician's initial document. Software that can extract information (such as coding and Quality Oncology Practice Initiatives [QOPI] measurements) directly from physician documentation, as well as perform other expensive and time-consuming chores, cannot be too far in the future.
CMS would also have us believe that after we get over an initial hump, ICD-10 will result in improved efficiency in billing offices, with a decreased need for supporting documentation for claims and fewer denials and appeals. Of course, they also see ICD-10 as a tool for identifying currently undetected fraud and abuse that is able to blend in with appropriate claims in the underpowered ICD-9.
Payers, like CMS, see a lot of good things in ICD-10. They view it as a simple cost and opportunity equation: an expensive implementation that is worth the opportunity it provides to more clearly identify the necessity of care. Payers and providers would both like the costs required in time-consuming pre-authorization of services to fall by the wayside. ICD-10, coupled with a critical appraisal of a payer's policies and procedures, could allow for significant streamlining, to the benefit of payers and providers alike.