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Ready or not! Here comes ICD-10
1. Laxmaiah Manchikanti1,
2. Frank J E Falco2,
3. Joshua A Hirsch3
2. 2Mid Atlantic Spine and Pain Physicians, Newark, Delaware, USA
3. 3Department of NeuroInterventional Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
1. Correspondence to Dr L Manchikanti, Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY 42003, USA; drlm{at}thepainmd.com

## Abstract

The International Classification of Diseases-10 (ICD-10) is a new system that is a federally mandated change affecting all payers and providers, and is expected to exceed both the Health Insurance Portability and Accountability Act (HIPAA) and Y2K in terms of costs and risks. In 2003, HIPAA named ICD-9 as the code set for supporting diagnoses and procedures in electronic administrative transactions. However, on 16 January 2009, the Department of Health and Human Services published a regulation requiring the replacement of ICD-9 with ICD-10 as of 1 October 2013. While ICD-9 and ICD-10 have a similar type of hierarchy in their structures, ICD-10 is more complex and incorporates numerous changes. Overall, ICD-10 contains more than 141 000 codes, a whopping 712% increase over the <20 000 codes in ICD-9, creating enormous complexities, confusion and expense. Published statistics illustrate that there are instances where a single ICD-9 code can map to more than 50 distinct ICD-10 codes. Also, there are multiple instances where a single ICD-10 code can map to more than one ICD-9 code. Proponents of the new ICD-10 system argue that the granularity should lead to improvements in the quality of healthcare whereas detractors of the system see the same granularity as burdensome. The estimated cost per physician is projected to range from $25 000 to$50 000.

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## Statistics from Altmetric.com

The US healthcare industry has been undergoing many changes and is poised to undergo many more radical changes in the coming years.1–6 The enormous pace of innovation in healthcare, increasing complexity of healthcare interventions and systems, pervasive and persistent unexplained variability in clinical practice and high rates of perceived inappropriate care combined with increased expenditures have helped fuel a steady increase in regulations and changes.7–18

The International Statistical Classification of Diseases and Related Health Problems, known as ICD, provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease.19 One significant policy change that we believe has been overshadowed by the current healthcare reform discussion is the ICD, 10th revision, or ICD-10.6 The rationale for transformation is that the greatly expanded ICD-10 coding system allows for more precision and specificity about both disease conditions and the healthcare interventions provided to patients; savings from elimination of inappropriate diagnoses and identification of fraud; and a suggestion that ICD-10 will allow the USA to report morbidity and mortality statistics to the WHO that are comparable with those of other countries.6 ,19 ,20

## ICD-10 changes for practice

Conversion of ICD-9-CM codes to ICD-10-CM codes will likely be very complicated. Supplementary table 1 (available online only) illustrates the select examples of codes utilized in neurointerventional practices, showing codes variable from 2 to 20 ICD-10 codes for each ICD-9 code. This example illustrates the complicated nature of conversion, creating further confusion. To understand the transition and mapping, one would need to expand multiple precious resources, including time and financial resources. Furthermore, as illustrated in table 3, one ICD-10 code represents multiple ICD-9 codes compounding the complexity and complications. The entire argument of granularity increasing and simplicity are lost with further restrictions than ICD-9.

Table 3

One ICD-10 code with multiple ICD-9 codes

## Practical impact

To help facilitate care and commerce, the government has invested in providing mappings between ICD-9 and ICD-10 and vice versa. There are two such mappings endorsed by CMS: the general equivalence mappings (GEMs) (for both ICD-9 to ICD-10 and ICD-10 to ICD-9) and the reimbursement maps (for ICD-10 to ICD-9 only). The GEMs established links among codes that are generally equivalent in each code set. The reimbursement maps were created after the GEMs maps and are more specific, identifying the top candidate mappings from within the GEMs.

Some published statistics30 may illuminate the challenges inherent in linking across the code sets. In the GEMs maps for procedures from ICD-9 to ICD-10, multiple examples are provided, although these are not specific to neurointerventional radiology or interventional pain management.6

• There are 255 instances where a single ICD-9 code can map to more than 50 ICD-10 codes.

• There are 119 instances where a single ICD-9 code can map to more than 100 ICD-10 codes.

Some GEMs maps of ICD-9 to ICD-10 are not specific:

• There are 7239 instances in the mappings for diseases where a single ICD-10 code can map to more than one ICD-9 code.

• There are 7241 instances in the mappings for procedures where a single ICD-10 code can map to more than one ICD-9 code.

In the reimbursement maps from ICD-10 to ICD-9:

• There are 3684 instances in the mappings for diseases where a single ICD-10 code can map to more than one ICD-9 code.

• There are 2135 instances in the mappings for procedures where a single ICD-10 code can map to more than one ICD-9 code.

Furthermore, different rules exist for different purposes. While CMS has tried to create clarity with GEMs and reimbursement mappings, the results are extremely disappointing. It has been shown that GEMs ICD-10 to ICD-9 mappings have a 5.1% exact match for diseases and only 0.1% exact match for procedures. In contrast, GEMs ICD-9 to ICD-10 mappings have an approximately 20.1% exact match for diseases and 1.2% exact match for procedures. With so few exact matches, it may be impossible for struggling practices to continue.

The troubles do not seem to stop with the different rules and different purposes and multitude of codes. They are also related to adopting software with multiple crosswalk variations. Independent package software vendors will have different offerings and divergent approaches to cross walking. Some may support sophisticated rules and others will not.30 Either way, if medical systems, claims systems and financial systems have different tools, things will become extremely difficult, causing hardship. On some occasions, it appears the data may have to be entered into multiple programs. Wollman30 describes that any business rules for mappings would need to be entered and stored in at least five systems, plus any analytic systems that source data from the applications. Thus with cross walking systems the potential for errors and rework is astronomical, due to the over 250 GEMs mappings, approximately 150 000 reimbursement mappings and over 160 000 ICD-9/ICD-10 codes used to manage a total of approximately 600 000 records and potentially tens of thousands of overrides in addition to the GEMs and reimbursement maps. Most prudent practices and providers require at least 3 years of historical data for trending and analysis purposes.

On September 30 2013, all of this history will be encoded in ICD-9 nomenclature. On the following day and going forward, the ‘new history’ will start to be encoded in ICD-10. Consequently, any type of trending will either require a migration of all of the history to ICD-10 or some mechanism for stepping up ICD-9 codes to ICD-10 or stepping back ICD-10 codes to ICD-9 for analysis. However, it may be necessary to use both. Considering other major issues, this may be a minor problem.

## Preparing for the inevitable

Appropriate preparation about switching to ICD-10 is of paramount importance. Some of the most important concerns are as follows:

1. Whether organizations will be able to undertake the huge array of changes to make the conversion possible.

2. Whether organizations can do so in time to meet the government imposed deadline of 1 October 2013 for the transition.

3. Where does the money come from and is US healthcare ready for more expenses.

Timing is crucial to manage practices in the USA. Most provider systems, health plans and software vendors, despite reporting that they are on schedule in their conversions to ICD-10 and the new electronic transaction format, it is evident that some have not even started their preparations. As an example, the American Hospital Association survey in October 2010 found that only one-half to two-thirds of hospitals had taken the recommended planning and assessment steps.19 Not surprisingly, many providers are not even aware of ICD-10 changes, let alone the implementation date. Very few physicians have completed the impact survey. This is a major issue for smaller practices.

## Conclusion

There are numerous issues related to ICD-10. None of the issues has been addressed appropriately as part of healthcare reform. Thus far, there is no scientific evidence for ICD-10 implementation based on the principles of evidence based medicine, as dictated by US authorities and world authorities. The US healthcare system has been overwhelmed with numerous regulations, many of which are not particularly well understood. ICD-10 will be a new blow to the healthcare system at a time when the Independent Payment Advisory Board (IPAB), Patient-Centered Outcomes Research Institute (PCORI) and other initiatives related to evidence based medicine, quality and access are struggling to come out.

The authors favor postponing implementation of ICD-10 and prefer a focus on core issues of improving care and access.

## Acknowledgments

We would like to thank Pain Physician for providing permission to publish in an abbreviated form.

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• ## Supplementary Data

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Files in this Data Supplement:

## Footnotes

• This paper is a brief version of Manchikanti L, et al. Necessity and implications of ICD-10: facts and fallacies. Pain Physician 2011;14:E405–25. This version is published with the consent of all of the authors and the permission of the journal Pain Physician.

• Competing interests None.

• Provenance and peer review Not commissioned; externally peer reviewed.

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