Which type of software was developed to enter icd-9-cm or icd-10-cm patient data for drg assignment?

Adv Wound Care (New Rochelle). 2013 Dec; 2(10): 588–592.

Abstract

The wound care industry will gain many benefits when International Classification of Diseases (ICD)-10-Clinical Modification (CM) is implemented. One of the main benefits is that the disease classifications will be consistent with current clinical practice and medical technology advances. The new classification codes will be very granular, which means the level of specificity will greatly improve. Numerous new codes will represent more specific anatomic sites, etiologies, comorbidities, and complications, and will improve the ability to demonstrate severity of illness. For instance, the new feature of laterality is directly built into the new codes: separate codes will distinguish right, left, and bilateral, where needed. The increased granularity will provide better analysis of disease patterns and outbreak of disease. Additionally, the United States will finally be using the same diagnosis coding system as the rest of the world. This article will describe what the ICD-9-CM/ICD-10-CM codes are, why they are so important, and how clinicians and researchers will convert from ICD-9-CM to ICD-10-CM effective October 1, 2014.

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

Introduction

What are the ICD-9-CM and ICD-10-CM coding systems?

The current diagnosis coding system used in the United States is International Classification of Diseases (ICD)-9-Clinical Modification (CM), which has an alphabetic index (Volume 2) and a tabular index (Volume 1). The ICD-9-CM system is used in all venues of healthcare to report diagnoses. ICD-9-CM is based on the official version of the World Health Organization's 9th Revision of the International Classification of Diseases (ICD-9). In 1977, a steering committee was formed by the National Center for Health Statistics (NCHS) to clinically modify ICD-9 for use in the United States. The term “Clinical” meant that the United States needed a useful tool to report diagnoses, to classify morbidity data for indexing, for medical care review, and to capture basic health statistics for all venues of healthcare.

In 1994, the NCHS began evaluating whether the existing ICD-10 developed by the World Health Organization (WHO) needed to be modified for use in the United States. ICD-10 was adopted by the WHO in 1990, with modifications made by Australia in 1998, and Canada in 2001. The ICD-10 is copyrighted by the WHO, which owns and publishes the classification. The WHO has authorized the development of an adaptation of ICD-10 for use in the United States for U.S. government purposes. The United States is the only industrialized nation that has not implemented ICD-10 for morbidity. The United States has used ICD-10-CM to code mortality since 1999. Since 1994, the NCHS has been developing the clinical modifications for use in the United States. The final rule for the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification to Medical Data Code Set Standards to adopt ICD-10-CM was published on January 16, 2009.1 The mandatory compliance date is October 1, 2014. Draft code sets and guidelines have been released in 2002, 2007, 2009, 2010, 2011, 2012, and the current version for 2013.

The current ICD-9-CM system consists of ∼13,000 codes and is running out of numbers. The new ICD-10-CM system is expanding to ∼68,000 codes and has flexibility for expansion. The ICD-9-CM codes have three to five characters, which are numeric with the exceptions of the V codes (factors influencing healthcare), E Codes (external causes of injury), and M Codes (neoplasm morphology) that begin with a single letter. The new ICD-10-CM codes have three to seven characters that are alphanumeric. Physicians created the ICD-10-CM terminology, whereas ICD-9-CM used the coding terminology. See Table 1 for a comparison of the two coding systems.

Table 1.

ICD-9-CM vs. ICD-10-CM comparison

ICD-9-CM code structure

ICD-9-CM has an alphabetic or numeric first digit; the remaining digits are numeric. Minimum of three digits, maximum of five digits; decimal after 1st three digits:

X X X . X X

Category (Digits 1–3) Etiology (4–5)

Anatomic site

Manifestations

ICD-10-CM code structure

ICD-10-CM starts with alpha (uses all letters except “U”); 2nd character always numeric; 3rd–7th characters can be alpha or numeric; decimal is always after 1st three digits:

X X X . X X X X

Category (1–3) Etiology (4–6) Extension (7)

Manifestation

Severity

ICD-10-CM placeholder characters: “x” is used as a dummy placeholder character.

• • Can be used as a 5th character for some six character codes and provides future expansion, while keeping the six character structure, OR

• • Can be used when a code has less than six characters and a 7th character extension is required to code the highest level of specificity.

• • Example 1: T37.0x1A Poisoning by sulfonamides.

• • Example 2: S01.02xA Laceration of scalp with Foreign Body scalp, initial encounter.

The official guidelines for use of the ICD-10-CM are approved by the cooperating parties for ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Centers for Medicare & Medicaid Services (CMS), and NCHS.2 Some of the guidelines are listed below:

• • Adherence to the guidelines when assigning diagnosis codes is required under HIPAA.

• • ICD-10-CM diagnosis codes are adopted under HIPAA for all healthcare settings.

• • Diagnoses are reported at their highest number of characters available.

• • Use appropriate codes to identify diagnoses, symptoms, conditions, problems, complaints or reason(s) for the encounter/visit.

• • Signs and symptoms are acceptable when a related definitive diagnosis has not been established or confirmed by the provider.

• • Signs and symptoms that are routinely associated with a disease should not be coded unless the classification instructs otherwise. Signs and symptoms not routinely associated with a disease should be coded.

• • There may be multiple codes to fully describe a single condition, such as Follow Use Additional Code, Code First, and Code if Applicable for any underlying causal conditions.

• • If subentries exist for acute and chronic conditions, code both and put acute first.

• • Combination Codes: single code used to identify two diagnoses, or a diagnosis with a secondary process or manifestation, or a diagnosis with an associated complication.

Discussion

How do you apply for new codes under the ICD-10-CM coding system?

The ICD-9-CM Coordination and Maintenance Committee is run by NCHS for diagnosis codes and CMS for procedure codes. These entities are responsible for any updates to the coding systems. They meet twice per year to review new coding proposals. The following information is taken from the March 5, 2013 Coordination and Maintenance Committee agenda:

“The ICD-9-CM Coordination and Maintenance Committee implemented a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of ICD-10 which would end 1 year after the implementation of ICD-10. The implementation of ICD-10 was delayed from October 1, 2013 to October 1, 2014 by final rule CMS-0040-F issued on August 24, 2012. (Links to this final rule may be found at: www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html)…

• • The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, 2011.

• • On October 1, 2012 and October 1, 2013 there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L. 108–173.

• • On October 1, 2014, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108–173. There will be no updates to ICD-9-CM, as it will no longer be used for reporting.

• • On October 1, 2015, regular updates to ICD-10 will begin.

The ICD-9-CM Coordination and Maintenance Committee will continue to meet twice a year during the partial freeze. At these meetings, the public will be asked to comment on whether or not requests for new diagnosis codes should be created based on the criteria of the need to capture a new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10 on and after October 1, 2015 once the partial freeze has ended.”3

Examples of proposals can be found in the minutes from the March 5, 2013 Agenda and Handouts.3

Why is the United States changing from ICD-9-CM to ICD-10-CM?

There are numerous reasons that the United States needs to change from ICD-9-CM to the ICD-10-CM system. The current ICD-9-CM coding system lacks specificity and detail. If the reader has attempted data extraction utilizing the ICD-9-CM system, you have probably encountered difficulty obtaining the exact diagnosis for which you were searching. For many research purposes, the ICD-9-CM diagnosis codes can be very broad, and lack the specificity to narrow the search.

ICD-9-CM is running out of code capacity to expand and keep up with advances in technology. Most of the categories contained in ICD-9-CM are completely full with no room for expansion. Another reason for the switch is the growing need for precise quality data. As many of you are already aware, payment systems are requiring quality measure collection for all venues of healthcare.

It has become increasingly difficult to compare costs and outcomes of different procedures, treatments, and technologies. The ability to obtain access to very specific data is vital to the success of many treatments. Clinical trials require specific information on comorbid conditions, adverse events, and past medical, surgical, and social histories. Another reason to convert is the inability of ICD-9-CM to support the U.S. initiative to transition to a health data exchange.

By converting to the new ICD-10-CM system, we will expect to obtain better data for (1) measuring the quality, safety, and efficacy, (2) researching, and (3) gaining more efficiency in our healthcare system. The new ICD-10-CM system will allow for future expansion to accommodate the rapid introduction of new technologies into the healthcare system. In addition, we will finally be able to align the United States data with other ICD-10 coding systems worldwide. There is an anticipated reduction in coding errors due to the specificity of the codes, and an overall lowering of costs and improving efficiencies in the healthcare system.

Increased granularity in the diagnosis coding will allow for better medical necessity justification, accurate reimbursement, and easier monitoring of quality data for outcomes. The specificity of the new codes will allow researchers access to more specific data for their research purposes.

ICD-10-CM diagnosis codes will tell the story of each patient encounter, describe etiologies of the disease process, explain the complications of care, provide a basis for medical necessity, support coverage for payment purposes, identify incidence of disease, and support statistical tracking for healthcare practices, as well as provide disease state information on medical practices across the continuum of care. The new system's granularity will play an important role in determining the severity of the patient's condition and contribute to research on treatment outcomes.

How do qualified healthcare professionals and researchers draw a connection between ICD-9-CM and ICD-10-CM?

General equivalence mappings

What are general equivalence mappings (GEMs)? GEMs assist in the translation from ICD-9-CM to ICD-10-CM. These files were developed to be able to link an ICD-9-10 code to their direct code link in ICD-10-CM, or vice versa. The most common users of the GEM files include, but are not limited to, professionals working in health information, medical research and informatics. Some terms to be familiar with while working with the GEM files are as follows.

• • A Single Entry is an entry in a GEM for which a code in the source system (the system you have) linked to one code option in the target system (system the codes are to be mapped to). For example, a researcher mapping an ICD-9-CM code to the best possible ICD-10-CM code might use the GEM file. This is known as a One-to-One code link. These GEM entries compare all possible One-to-One maps of an ICD-9-CM to an ICD-10-CM code or the reverse. An example of a One-to-One code link is ICD-9-CM: 250.11 diabetes with ketoacidosis type 1 not stated as uncontrolled ICD-10-CM: E10.10 Type 1 diabetes mellitus with ketoacidosis without coma

• • A Combination Entry is an entry in GEMs for which a code in the source system must be linked to more than one code option in the target system. This is known as One-to-Many code mapping. Often times, it takes more than one code to satisfy all of the meaning contained in one code in the other system. An example of a One-to-Many mapping might be coding nonpressure ulcers. In the ICD-9-CM system, nonpressure ulcers are coded by site. In the ICD-10-CM system, ulcer codes contain more information such as laterality, specification of skin breakdown, fat exposed, muscle necrosis, bone necrosis, or unspecified severity. The anatomic sites are also much more specific. Therefore, it may take multiple codes in ICD-10-CM to describe the same ulcer with one code in the ICD-9-CM system.

Caution

Mapping is not a straightforward correlation between the codes. The user is responsible to evaluate the documentation in the medical record, the coding choices provided, and to reference the ICD-10-CM code book to verify the ultimate code selection.

There are two types of GEM files on the CDC's FTP site.4 They are:

• 1. From ICD-9-CM to ICD-10-CM: known as forward mapping

• 2. From ICD-10-CM to ICD-9-CM: known as backward mapping

The GEM files give the most likely choice or best compromise between codes. However, please be aware that the GEMs are not crosswalks. They are reference mappings, designed to help the user navigate the complexity of translating meaning from one code set to the other.

Researchers should pay special attention to the GEM files. For instance, if clinical studies were initiated before October 1, 2014, researchers should be able to map from one coding system to the other for continuity of data collection. Researchers need to look at the current ICD-9-CM codes used for data collection in their study(ies), and be able to translate the ICD-9-CM codes into ICD-10-CM codes so that data collected over multiple years will be able to be combine utilizing the GEM files as a guide for the process.

Conclusion

The new ICD-10-CM coding system set for implementation on October 1, 2014 will provide users of clinical healthcare data the ability to get more specific with morbidity data. The new features included in the ICD-10-CM coding system will allow for expansion, and tools have already been developed to assist in the transition to ICD-10-CM. Now is the time to begin this important transition process by performing an assessment of your currently collected coded data in ICD-9-CM, and plan the education, system training, system integration, and documentation improvement that must be accomplished. Accurate and detailed documentation will assist in the transition and will assist coders in determining the correct code based on the documentation contained in the medical record. Scientists, manufacturers, and qualified healthcare professionals who are conducting clinical research should identify research projects that will overlap the two coding systems based on the October 1, 2014 mandatory compliance date. If the research project will overlap both the ICD-9-CM and ICD-10-CM systems, the researcher should develop a plan to forward map or backward map the tracked diagnosis codes. We have completed the review of What, Why, and How of ICD-10-CM…now it is up to you to plan to incorporate ICD-10-CM into your wound care practice and/or your wound care research!

Abbreviations and Acronyms

Resources

Additional information can be found on the NCHS website:5

• 2013 Index to Diseases and Injuries

• 2013 Tabular Listing of Disease and Injuries

• 2013 Official Guidelines for Coding and Reporting

• 2013 Index to External Causes

• 2013 Mapping of ICD-9-CM to ICD-10-CM and ICD-10-CM to ICD-9-CM

Author Disclosure and Ghostwriting

No competing financial interests exist. The content of this article was expressly written by the author listed. No ghostwriters were used to write this article.

About the Author

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, is Senior Director of Strategic Reimbursement for Integra LifeSciences Corporation in Plainsboro, NJ. Donna is an AHIMA approved ICD-10-CM Trainer and has been designated as a Fellow of the AHIMA. She is a member of the Editorial Advisory Board of Today's Wound Clinic magazine, member of the Association for the Advancement of Wound Care, and was awarded Woman of the Year in Healthcare by the National Association of Professional Women. Ms. Cartwright can be reached at 609-936-2265 for questions or by email at

References

Articles from Advances in Wound Care are provided here courtesy of Mary Ann Liebert, Inc.