Why We Can’t Skip ICD-10

HHS’s intended delay of ICD-10 implementation has led to suggestions that the US simply skip ICD-10 altogether and wait for the next revision. It is true that ICD-11 is under development, but it is not as close as many perceive and the US simply cannot wait any longer to reverse the deterioration of its health data.

There is a cost and a danger to using the outdated ICD-9-CM coding system. Its continued use will increasingly have an adverse impact on the value of healthcare data, including the accuracy of decisions based on faulty or imprecise data. The more time passes without implementing the ICD-10 code sets, the more the quality of healthcare data will suffer.

ICD-9-CM is obsolete and no longer reflects current clinical knowledge, contemporary medical terminology, or the modern practice of medicine, and its limited structural design lacks the flexibility to accommodate advances in medicine and medical technology. There is no viable long-term solution for extending the life of ICD-9-CM.

The US healthcare system is allowing its data to deteriorate at the very time it is increasing its demands for high-quality data that can support healthcare initiatives to improve care delivery and reform payment. As long as ICD-9-CM is in use, US coded data will grow more imprecise with each year that passes.

Continued use of ICD-9-CM only hinders US efforts to gather clinically relevant and internationally comparable data. The US has been using ICD-10 for mortality reporting since 1999, so continued use of ICD-9-CM prolongs the time in which US mortality and morbidity data are not comparable.

Finally, delaying ICD-10 implementation will only increase the costs of the conversion. Costs associated with both the implementation of the code set and the negative impact of continued deterioration of healthcare data on the efficiency and effectiveness of the US healthcare system would continue to escalate.

Since the final rule was published in 2009, the healthcare industry and government agencies have made tremendous investments in the ICD-10-CM/PCS transition. Transitioning to ICD-10-CM and ICD-10-PCS now will provide a mechanism for tightening the linkage between classifications and their applications in electronic health records, with broad implications for improving patient quality, safety, public health surveillance, and the adoption of clinical best practices.

The ICD Evolution

ICD, or the International Classification of Diseases, is a member of the World Health Organization’s (WHO) Family of International Classifications. WHO expected to revise ICD every 10 years.

The last revision, ICD-10, was adopted by the World Health Assembly in 1990. The next revision, ICD-11, is expected to be adopted by the World Health Assembly in 2015. The beta version is expected to be released in May 2012, but it will be incomplete and will continue to evolve.

The US clinical modification of ICD-10 (ICD-10-CM) was developed in the 1990s, following the WHO release of ICD-10 in 1993. The modification addressed a wide variety of US user needs and reflected advances in clinical knowledge since the development of ICD-10. ICD-10-CM is updated annually to keep pace with medical advances and address ongoing user needs.

ICD-10-CM represents a significant improvement over both ICD-9-CM and ICD-10. Examples of attributes added to the US clinical modification include expanded distinctions for ambulatory and managed care encounters, requested expansion in levels of specificity to address, research, quality measurement, public health, or reimbursement purposes, and the inclusion of modifications to ICD-9-CM that had not been incorporated into ICD-10. The WHO ICD does not include procedure codes. For this reason, ICD-10-PCS was developed under contract to the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) as a replacement for the ICD-9-CM procedure coding system.

ICD-11’s Development

ICD-11 is under development, and it could be adopted by the World Health Assembly in 2015. However, that doesn’t mean it will be ready for use in the US any time soon.

Once ICD-11 is officially adopted by the WHO the US must undertake its own process to review and potentially adapt the revision—a process that could put the US implementation of ICD-11 a decade into the future.

Further, skipping ICD-10 will make a transition to ICD-11 more difficult. ICD-10-CM is the pathway to ICD-11. It will inform the ICD-11 development process. Conversion to ICD-10-CM/PCS now will provide an easier and smoother transition to ICD-11 than attempting to transition from ICD-9-CM.

ICD-11 development will draw heavily from the development of ICD-10-CM, as updated clinical knowledge and additional detail considered important for use cases such as quality and patient safety monitoring have been incorporated. As the WHO Collaborating Centre for the Family of International Classifications for North America, the US National Center for Health Statistics is actively involved in ICD-11 development.

Just as modifications to the WHO ICD-10 have been incorporated into ICD-10-CM during the annual ICD-10-CM updating process, it is anticipated that content additions in the final version of ICD-11 that are not already present in ICD-10-CM will be incorporated in ICD-10-CM over time, through the ongoing update process, facilitating the eventual US transition from ICD-10-CM to ICD-11.

However, due to the structural limitations and obsolete nature of ICD-9-CM, modifications to ICD-9-CM to keep it in sync with the WHO version would be impossible, and thus transitioning from ICD-9-CM to ICD-11 would be much more complicated and disruptive.

It will likely be another decade before ICD-11 can be implemented in the US. An assessment as to whether a US clinical modification of ICD-11 is needed in order to support US health information requirements for annual updates would need to be conducted. The process of developing a clinical modification, followed by review, solicitation of public comments, and further refinement based on review and comments, would take several years. Only then could a rulemaking process to adopt ICD-11 as a HIPAA code set be initiated.

In the case of ICD-10, eight years passed between the endorsement by the World Health Assembly and the completion of ICD-10-CM. Another twelve years transpired before a final rule was issued. The US cannot wait that long to improve its health data.

Sue Bowman is director of coding policy and compliance at AHIMA.

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