Necessity and Implications of ICD-10: Facts and Fallacies

The International Classification of Diseases-10 (ICD-10 is a new system that is expected to beimplemented effective on October 1, 2013. This new system is a federally mandated changeaffecting all payers and providers, and is expected to exceed both the Health InsurancePortability and Accountability Act (HIPAA) and Y2K in terms of costs and risks. However,the Administration is poised to implement these changes at a rapid pace which could beproblematic for health care in the United States.In 2003, HIPAA named ICD-9 as the code set for supporting diagnoses and procedures inelectronic administrative transactions. However, on January 16, 2009, the Department ofHealth and Human Services (HHS) published a regulation requiring the replacement of ICD9 with ICD-10 as of October 1, 2013. While ICD-9 and 10 have a similar type of hierarchy intheir structures, the ICD-10 is more complex and incorporates numerous changes. Overall,ICD-10 contains over 141,000 codes, a whopping 712% increase over the less than 20,000codes in ICD-9, creating enormous complexities, confusion, and expense. Multiple publishedstatistics illustrate that there are approximately 119 instances where a single ICD-9 codecan map to more than 100 distinct ICD-10 codes, whereas there are 255 instances where asingle ICD-9 code can map to more than 50 ICD-10 codes. To add to the confusion, there are3,684 instances in the mapping for diseases where a single ICD-10 code can map to morethan one ICD-9 code.Proponents of the new ICD-10 system argue that the granularity should lead to improvementsin the quality of health care, since more precise coding that more accurately reflects actualpatient conditions will permit smarter and more effective disease management in pay-forperformance programs. This, in essence, encapsulates the benefits that supporters of thisnew system believe will be realized, even though many of these experts may not be involvedin actual day-to-day medical practices.Detractors of the system see the same granularity as burdensome. The estimated cost perphysician is projected to range from $25,000 to $50,000. Further, they argue that the ICD10 classification is extremely complicated, and expensive. Concerns exist that it is beingimplemented without establishing either the necessity or thinking through the unintendedconsequences. Opponents also argue that beyond financial expense, it is also costlyin terms of human toll, hardware and software expenses and has the potential to delayreimbursement. There is also concern that an unintended consequence of granularity wouldbe the potential for enhanced and unnecessary fraud and abuse investigations.The authors of this article favor postponing the implementation of the ICD-10 until such timeas its necessity is proven and implications are understood.Key words: Diagnostic coding systems, International Statistical Classification of Diseasesand Related Health Problems (ICD), ICD-9-CM, ICD-10-CM, regulations, growth, evidencebased literature, reimbursement, claims, Health Insurance Portability and Accountability Act(HIPAA)