Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) have worked diligently to revise and update the International Classification of Diseases (ICD) in order to provide United States based medical professionals with a comprehensive and consistent classification system for diagnoses. All health care providers covered under the Health Insurance Portability Accountability Act (HIPAA), including Medicare and Medicaid, in order to standardize diagnoses for medical and billing purposes, will use these classifications. The goals of these changes include improving effectiveness of patient care, safety, and health outcomes, and an improved medical coding and billing system for all health practices and organizations using ICD-10.
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Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
1. All member countries of the World Health Organization (“WHO”) require ONLY the ICD diagnostic coding for the wide-range of healthcare services except _____________________.
b) the Congo
c) the United States
2. Medical coding and billing personnel
a) are not part of the healthcare workforce.
b) make up one-fifth of the healthcare workforce.
c) make up one percent of the healthcare workforce.
d) have decreased under ICD.
3. The second character of the medical and surgical procedures section codes reflects the general body system, for example, _______________.
b) the duodenum
c) a device such as a synthetic substitute
d) small intestine
4. True/False: The International Statistical Classification of Diseases (ICD) provides an international, standardized medical diagnosis and billing system.
5. The root operation presents the ______________ of the procedure.
c) access location
The ICD-10 is the revised version of the International Statistical Classification of Diseases (ICD) and related health problems, a medical classification list issued by the World Health Organization (WHO). It contains the codes for diseases, their signs and symptoms (physical complaints and unusual findings), social and legal circumstances, and external reasons behind diseases of injury.1 The code set has over 14,400 different codes and enables the tracking and diagnosis of a number of new diseases. These codes can be expanded to more than 16,000 codes by utilizing the optional sub-classifications given. The comprehensive details provided by the ICD can be further increased with a simplified multi-axial approach.
Why is ICD-10 relevant to nurses? Nurses provide direct patient care in multiple settings and are required to document precise patient symptom descriptions and well-defined care outcomes. As the need to standardize medical diagnosis and billing systems develops in the United States, and internationally, all members of the health team will need to be educated and updated on documentation and medical record systems, as well as medical coding and billing criteria. Diagnoses in multiple subspecialties have revised numerical codes and narrative descriptors, including diagnostic specifiers that care providers will need to stay informed about.
The entire health industry has shown agreement to adopt the ICD-10 since it provides more information in order to have better health results and to eventually reduce healthcare cost. Certain issues remain and are evolving; such as claims submitted with unspecified codes instead of a more specific ICD-10 code.
ICD-10: Standard Diagnostic Tool For Health Management
The International Statistical Classification of Diseases is the standard diagnostic tool for health management, epidemiology, and clinical purposes. This includes the evaluation of the general health scenario of population groups. It is used for assessing the incidence and prevalence of diseases and other kinds of health problems, providing a picture of the general health situation of various regions and populations. The World Health Organization (WHO) has provided detailed information about the new ICD-10 along with relevant digital material involving training and online support, such as ICD-10 downloadable study guides.
The ICD is used by nurses, physicians, researchers, health providers, health managers and coders, policy makers, health information technology workers, patent organizations and insurers to categorize the diseases and other health related problems recorded on various kinds of health records, including death certificates. Along with enabling the storage and retrieval of diagnostic information for epidemiological, clinical and quality purposes, these records are the basis for the compilation of national morbidity and mortality statistics by WHO member nations.
Lastly, the ICD is used for the resource allocation and reimbursement decision making by many countries. It is interesting to note that although U.S. healthcare providers have been required to adhere to ICD-10 coding since October 1, 2015, the U.S. is the only nation in the world that requires a two-tiered reporting system, which includes the Centers For Medicaid and Medicare Services (CMS). All other countries, including Canada, only require the ICD diagnostic coding for a wide-range of healthcare services as reviewed by the WHO.
All WHO member nations use the ICD, which has also been translated into 43 languages. Most countries use ICD to report mortality data, which is a major indicator of health status in a country. ICD-10 was endorsed by the 43rd World Health Assembly in 1990, and came into use in 1994.1 ICD is still under revision, through a current revision process, and the release year for ICD-11 has been declared as 2018.1
The ICD-10 is important to medical coding and billing associates, because the ICD is the common system of codes classifying every health problem or disease that needs to be coded. The diagnosis codes reflect a generalized explanation of the injury, disease or health problem that was the catalyst for the patient-physician encounter. A biller-coder uses the ICD-10 on a daily basis.
The 9th edition of the ICD (ICD-9) was used in the U.S. since 1979. The ICD-10, however, is not only an update of the old version, it is a new edition that includes all codes rearranged and positioned in different areas. Additionally, the ICD-10 involves significant differences as compared to ICD-9; such as, ICD-9 has more than 14,000 diagnosis codes and around 4,000 procedural codes whereas ICD-10 has more than 68,000 diagnosis codes and over 72,000 procedural codes. Other differences are based on how the codes are presented (for instance, the number of characters), and how these are interpreted (decoding the characters to determine what specific groupings mean).
Changing over to ICD-10 is considered an improvement. Presently, medical coding and billing requirements make up one-fifth of the healthcare workforce, which is a number that is growing. Shifting to ICD-10 has resulted in an increased demand for medical coders, since it would make the billing and coding process more time consuming and complicated. Additionally, the ICD-10 implementation in the U.S. will influence practice roles for licensed medical providers and nurses working in both private and public health practices. This new system of coding and billing will influence all aspects of the health industry with the ultimate goal to improve patient care and outcomes. It will be critical for health providers, including medical and nursing clinicians, to understand the new documentation requirements for ICD-10, and, specifically how it could impact the historical role of nurse informaticists.
The initial sections discussed here highlight the basic code structure, definitions and terms important for health members to understand new diagnostic codes and descriptors pertaining to health specialties and conditions treated. Although coding to underlying disease has changed dramatically with ICD-10, the purpose of this article is not to delve into the minutiae of coding symbols and alternate classifications for the purpose of compiling statistics. Such details will be omitted here to allow for a sharper focus on new ICD classifications related to medical diagnostic descriptors and relevant discussion surrounding morbidity and mortality pertaining to particular diseases and conditions.
The compliance date for the execution of ICD-10 was October 1, 2015, for all Health Insurance Portability and Accountability Act (HIPAA) covered entities. The U.S. initiated the ICD-10-CM (“CM” means clinical modification) for medical diagnoses based on the ICD-10 as developed by the WHO; and, furthermore, the U.S Centers for Medicare and Medicaid Services (CMS) developed a new Procedure Coding System (PCS) for inpatient procedures. The ICD-10-CM replaces all prior diagnostic coding systems in every healthcare setting beginning October 1, 2015 and forward. The ICD-10-PCS, including the ICD-10-PCS official Guidelines for Coding and Reporting, would also replace the ICD-9-CM procedure codes.2 This will be further elaborated on later on.
Changes to the ICD Coding System
Changes to the ICD coding system involve the following criteria, as briefly outlined below. This section will help to prepare the learner develop a general understanding of how terms will be used in the ICD-10 to define health conditions and treatments. Although, coding system criteria can be construed as inherently dry to health professionals required to know it, learners may approach the recommended learning as general knowledge needed in order to understand what is expected from health professionals to adhere to ethical coding and billing practices that influence patient care outcomes, and for future regional and national panel discussions related to improving U.S. healthcare system coding and descriptors for medical treatment. Moreover, as increased numbers of nurses and physicians become involved in ICD practices within a national and global arena, the discussion within U.S. healthcare teams promises to be more robust and rewarding as patient care outcomes are continuously reviewed.
Laterality (side of the body affected) has been added to the relevant code.3 Examples of laterality include: right, left, and bilateral. ICD-10 codes include:
L89.012 - Pressure Ulcer of right elbow, stage II
D27.0 - Benign neoplasm of right ovary
I63.412 - Cerebral infarction due to embolism of left middle cerebral artery
C50.511 - Malignant neoplasm of lower-outer quadrant of right female breast
H16.013 – Central corneal ulcer, bilateral
L89.012 – Pressure ulcer of right elbow, stage II
Diseases specified under laterality, right and left, include:
Code Structure The ICD-10 code set has been expanded to seven positions from five positions (first one alphanumeric, and others numeric). The codes use alphanumeric characters in all positions, not only the first position like in the ICD-9. While the following may not hold interest for many clinical persons, it is important to briefly summarize the ICD code structure that has relevance to health informaticists and administrative staff with a role in diagnostic coding and billing. The code structure in ICD-10 can be summarized as follows:3
3-7 characters (instead of 3-5 characters as in ICD-9)
Character 1 is alpha, where all letters except U are used (unlike ICD-9 where first character is numeric or alpha [E or V])
Character 2 is numeric whereas character 3-7 are alpha or numeric (unlike ICD-9 where characters 2-5 are numeric)
Use of decimal after 3 characters (like in ICD-9)
Alpha characters are not case sensitive
There is use of a dummy placeholder “x” in ICD-10. This dummy placeholder is used with some codes to allow for potential future expansion and/or to fill out empty characters when a code contains less than 6 characters and a 7th character applies. When a placeholder character appears, it must be placed in order for the code to be recognized as valid.3
Number of Codes
As indicated earlier, existing codes have significantly increased to a current number of 69,000, as compared to the ICD-9 that had 14,000.4 The new code set gives a significant increase in the specificity of the reporting, enabling more information to be delivered in a code. The terminology has also been modernized and has been made more consistent throughout the code set.
The ICD-10 has expanded the severity parameters, unlike ICD-9 that has limited severity parameters.
The ICD-10 has expanded the combination codes for capturing the complexity of patients in a better way. The combination codes used, increase specificity and the “x” placeholder illustrations can be seen in Table 1 below.4
Atherosclerotic heart disease of native coronary artery with unstable angina pectoris.
Non-displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing.
Malignant neoplasm of lower-outer quadrant of right female breast.
Malignant neoplasm of lower-outer quadrant of left female breast
The ICD-10 has two kinds of exclude notes, while ICD-9 has just one type. The types of exclude notes are type 1 and type 2, which are described as follows:5
Excludes Note Type 1:
The type 1 excludes note is a pure exclude note, implying “not coded here”. It indicates that the code excluded should never be used at the same time as the code above the excludes note type 1. This is used when two conditions cannot take place together, like a congenital condition versus an acquired kind of the same condition.
Excludes Note Type 2:
The type 2 excludes note reflects the criteria of “not included here.” It shows that the condition excluded is not the part of the condition reflected by the code; however, a patient might be having both conditions at the same time. If an excludes note type 2 appears under a code, it is acceptable to use both the code and excluded code together, where appropriate.
In certain cases, new code definitions are given in ICD-10 reflecting modern medical practices. For example, the definition of acute myocardial infarction is now four weeks instead of eight weeks.
Anatomy and Restructuring
In ICD-10, injuries are categorized by anatomical site instead of by the type of injury.
Category restructuring and code reorganization have taken place in a number of ICD-10 chapters, leading to the classification of some disorders and diseases that are different from ICD-9.5
Some diseases have been categorized into different sections and chapters in order to show present medical knowledge.5
Summary of the Changes
The summary of the changes between ICD-9 and ICD-10 are listed in Table 2 below. The table identifies diagnosis descriptors important to clinicians, coders and billers.
CD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
Right or Left account for >40% of codes
Extensive Combination Codes to better capture complexity types of Exclude Notes
2 types of Exclude Notes
The National Center for Health Statistics (NCHS), the federal agency having the authority and responsibility for use of ICD-10 in the United States, has also created a clinical modification of the classification for morbidity purposes. The ICD-10, as mentioned earlier, is used for coding and classifying mortality data for death certificates. As mentioned earlier, it replaced the ICD-9 for this purpose on January 1, 1999. The ICD-10-CM is the replacement for the ICD-9, Volumes 1 and 2, which would be effective and implemented from October 2015.6
The ICD-10 is copyrighted by the WHO, which owns and issues the classification system. The WHO has authorized the development of an adaptation of ICD-10 for use in the United States for governmental purposes.6 All the changes and modifications to the ICD-10 must comply with WHO conventions for the ICD. A Technical Advisory Panel and vast additional consultation with clinical coders, physician groups and others to ensure clinical utility and accuracy developed the ICD-10 after a comprehensive analysis.
The whole draft of the Tabular list of ICD-10, and the initial crosswalk between ICD-9 and ICD-10 were made accessible on the NCHS website for public opinion. This opinion period was between December 1997 and February 1998. The American Health Information Management Association and the American Hospital Association executed a field test for ICD-10 in 2003. All suggestions, comments and results of field test were reviewed, and more changes to ICD-10 were made on the basis of those suggestions. In addition, new concepts have been integrated to the ICD-10 on the basis of the established updated procedure for ICD-9 and the WHO’s ICD-10. This represents ICD-9 changes from 2003-2011 and ICD-10 changes from 2002-2010.6
The clinical codes and descriptors in ICD-10 represent significant improvement over ICD-9. Particular improvements include the addition of information related to ambulatory and managed care encounters, creation of combination diagnosis codes and symptoms for decreasing the number of codes required to completely explain the condition, expanded injury codes, the addition of sixth and seventh characters, integration of common fourth and fifth digit sub classification, laterality, and higher specificity in code allocation. The new structure would enable more expansion than was possible or expected within the ICD-9.
All Health Information Portability and Accountability Act (HIPAA) covered entities must start using ICD-10 codes by October 1st 2015, as made compulsory by the U.S. Department of Health and Human Services. The implementation deadline of ICD-10 has been delayed many times. The ICD-10 guidelines were primarily established to replace ICD-9 on October 1, 2013. Two separate yearlong delays to the implementation of ICD-10 pushed its implementation to 2015.6
As previously noted in the table above reflecting summary of changes since ICD-9, the structure of the ICD-10 code includes the following:
The first character must be an alpha character, excluding “u”.
The second and third one are numeric.
The characters from four till seven can be a combination of numeric and alpha character.
The first three characters classify the injury.
The fourth through sixth characters explain in detail the cause, anatomical site, and severity of the illness or injury.
The seventh character is an extension digit, and used to categorize an initial, after or sequel (late affect) treatment encounter.