# Presentation: 174177

## The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification

**David Berglund, MD, MPH**
**Office of the Center Director**
**National Center for Health Statistics**

## World  Health Organization

- As of July 2000, W.H.O. had authorized the publication of ICD-10 versions in 37 languages.
- 138 countries have implemented ICD-10 for mortality
- 99 countries have implemented ICD-10 for morbidity
- ICD-10 was implemented for mortality reporting in the United States 1/1/99.
- Several countries use ICD-10 or a clinical modification in casemix and reimbursement systems
- United Kingdom [1995], Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) [1994-1997], France [1997], Australia [1998], Belgium [1999], Germany [2000], Canada [2001]

## ICD-10 Major Changes

- Alphanumeric codes (A00-Z99)
- Restructuring certain chapters/ categories
- Addition of new features
- Expansion of detail (2,033 categories; 855 more than ICD-9)

- ICD-10 represents the broadest scope of any ICD revision to date.  Changes include:

## Review of ICD-10-CM Development

- Why a Clinical Modification?
-    Need to:
- Expand to include new concepts: emerging diseases and more recent medical knowledge
- Incorporate changes made to ICD-9-CM since ICD-10 implementation
- Expand distinctions for ambulatory and managed care encounters

## ICD-10-CM Development

- Four phases of development
- Phase 1 - Prototype developed under contract
- 			20 Technical Advisory Panel members
- Phase 2 - Enhancements by NCHS
- 			C&M minutes, providers & other users
- Phase 3 - Further enhancements based on public
- 			comments, of 22 organizations/individuals
- Phase 4 - Pilot test, and updates based on comments

**Notes:**
Phase 1
CMS, AHRQ, AHA, physician groups

Phase 2
Review of 15 years of proposals to modify ICD-9-CM

Phase 3
1,243  comments from 22 organizations & individuals

	238	No further action
	448	Incorporation
	  77	Require further study
	480	Inconsistent with  structure/ 			conventions

## ICD-10-CM Development

- Consultation with:
- Physician groups
- Dermatology, Neurology, Obstetrics & Gynecology, Orthopedics, Pediatrics, Psychiatry, Urology
- Professional organizations
- ADA, AHA, AHIMA, ANA, NACHRI
- Other users of ICD-9-CM
- federal agencies, Workers Comp, epidemiologists, researchers

**Notes:**
Dermatology, Neurology, orthopedics, pediatrics, diabetes, nursing, Urological, psychiatric, NACHRI, burns assoc.,

## ICD-10-CM DevelopmentMajor Modifications

- Addition of sixth character, and seventh character extensions (OB, injuries, external causes)
- Addition of detail (e.g., laterality, OB trimesters)
- Expanded codes (e.g., injury, diabetes)
- Revised codes (e.g., diabetes)
- Combining certain codes:
- dagger/asterisk codes
- diagnosis / symptom codes
- Deactivating procedure codes

## Example - Diabetes mellitus ICD-10-CM reflects revisions to diabetes classification by the American Diabetes Association

| ICD-9-CM
250.X
4th digit identities type of complication
5th digit “1” identified juvenile-onset
5th digit “0” identified adult-onset | ICD-10
E10.X  Insulin-    dependent
E11.X  Non-insulin      dependent
E12 Malnutrition-     related
E13 Other specified
E14 Unspecified
4th digit for type of complication | ICD-10-CM
E08 Diabetes due to underlying condition
E09 Drug or chemical induced diabetes 
E10 Type 1 diabetes 
E11 Type 2 diabetes 
E13 Other specified diabetes mellitus
E14 Unspecified
4th, 5th, and 6th digits identify type of complication |
| --- | --- | --- |

## Example - Injury codes

- ICD-9-CM
- 880   Open wound of shoulder and upper arm
- 		880.0 Without mention of complication
- 		880.1 Complicated
- 		880.2  With tendon involvement
- 5th digit for site (e.g., shoulder: 0; scapular region: 1....)
- ICD-10-CM
- S41.0  Open wound of shoulder
- 		S41.01x  Laceration without foreign body of shoulder
- 		S41.02x  Laceration with foreign body of shoulder

## ICD-10-CM Injury Example: Sixth digits & Seventh Character Extensions

- Injury laterality, 6th character: 1: right, 2: left, 9: unspecified
- Seventh character extensions for injury and external cause codes
- a: Initial encounter, d: Subsequent encounter, q:	Sequelae
- Examples:
- S41.011a  Laceration without foreign body of right shoulder, initial encounter
- S41.022d  Laceration without foreign body of left shoulder, subsequent encounter

## ICD-10-CM Field Testing AHA/AHIMA September 2003

- Total 6,177 records coded from a spectrum of providers:
- Short-term acute care inpatient (42.3%)
- Short-term acute care outpatient (38.8%)
- Post-acute settings (7.9%)
- Physician practices (6%)
- Clinics, community health centers, free-standing ambulatory surgery centers, and free-standing diagnostic facilities (2.9%)
- Behavioral health facility (1.6%)
- Other (0.6%)

## ICD-10-CM Field Testing AHA/AHIMA, continued

-   Participant Feedback:
- Clinical descriptions thought to be better than ICD-9-CM (71.7%)
- Notes, instructions/guidelines thought to be clear and comprehensive (64.5%)
- ICD-10-CM felt to be an improvement over ICD-9-CM (76.3%)
- Migration to ICD-10-CM supported by respondents (83.6%)
- Majority of respondents indicated would need 16 hours or less of training
- Recommend training be provided three months prior to        ICD-10-CM implementation

## Plans for ICD-10-CM Maintenance

- Maintain in Relational Database Management System (Microsoft SQL Server)
- Benefits of maintaining in a database:
- Enables output to multiple distribution formats
- Supports updates more easily
- Users can easily load into database systems
- Facilitates creation of mappings from other terminologies
- Enables development of systems for data exchange
- Benefits those transitioning from ICD-9-CM

## ICD-10-CMStatus

-  Incorporation of public comments
-  Revisions to:  Tabular List, Index, Crosswalks, Guidelines
-  Database (Alpha version)
-  Incorporation of pilot test comments (in progress)
-  Completion of database system
-  Further revision of crosswalk from ICD-9-CM
-  Develop training materials

## ICD-10-CM Implementation Benefits and Issues

- Training will be required for users at various levels
- Coders should not need extensive retraining, since structure, conventions, and coding rules are basically the same
- Some short-term loss of productivity expected
- Will require changes to data systems
- Will enable improvements in data retrieval/analysis
- Will support creation of mappings from other terminologies; crosswalk from ICD-9-CM needed
- Will enable development of systems for data exchange

## NCVHS Hearings and Impact Analysis

- NCVHS has conducted extensive hearings since 1997 on           ICD-10-CM and ICD-10-PCS
- RAND commissioned by NCVHS to conduct impact analysis of moving to ICD-10-CM & ICD-10-PCS
- assessment of full range of implications on current users
- costs and benefits (quantifiable and nonquantifiable)
- impact of transition timing, and benefits of improved data
- In September 2003:  RAND presented a pre-final report, concluding the benefits of ICD-10-CM outweigh the costs
-      Outside parties presented independent reports (including AMA on cost of ICD-10-PCS, and Blue Cross Blue Shield cost analysis)
-      AHA/AHIMA presented final report on ICD-10-CM pilot test

## NCVHS Recommendations on ICD-10-CM and ICD-10-PCS, November 2003

- Conclude it is in US’ best interest to adopt   ICD-10-CM and -PCS to replace ICD-9-CM
- Two year implementation period after final rule
- NPRM to invite comments on how to:
- Minimize cost	 – Ensure smooth migration
- Maximize benefits 	 – Consider timeframes
- Mitigate unintended consequences

## Web Sites

_**NCHS Classification of Diseases**_**:**
**ICD-9-CM, ICD-10, ICD-10-CM, and ICF**
**     ****http://www.cdc.gov/nchs/icd9.htm**
**        **
_**National Committee on Vital and Health Statistics**_**:**
**http://www.ncvhs.hhs.gov**
_**Centers for Medicare and Medicaid Services**_**:**
**ICD-10-PCS**
**http://www.cms.hhs.gov/paymentsystems/icd9/icd10.asp**