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The ICD-10 system: a gift that keeps on taking
  1. Joshua A Hirsch1,
  2. Thabele M Leslie-Mazwi1,
  3. Gregory N Nicola2,
  4. Rahmi Oklu3,
  5. Kurt A Schoppe4,
  6. Ezequiel Silva III5,6,
  7. Laxmaiah Manchikanti7,8
  1. 1Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Hackensack University Medical Center, Hackensack, New Jersey, USA
  3. 3Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  4. 4Radiology Associates of North Texas, Fort Worth, Texas, USA
  5. 5South Texas Radiology Group, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  6. 6University of Texas Health Science Center, Department of Radiology, San Antonio, Texas, USA
  7. 7Pain Management Center of Paducah, Paducah, Kentucky, USA
  8. 8Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
  1. Correspondence to Dr Joshua A Hirsch, Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Hirsch{at}


The Protecting Access to Medicare Act of 2014 was signed into law on April Fool's Day. Indeed, 2014 saw unprecedented enthusiasm for the possibility of a permanent solution to the sustainable growth rate formula. Congress failed to come together on methods to pay for that fix. Instead, Congress provided another temporary patch on April 1. As part of that law, International Classification of Diseases-10 (ICD-10) adoption was pushed back by at least 1 year until, at the earliest, October 1, 2015. While many physicians support the delay in ICD-10 implementation, there are those that disagree.

  • Economics

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The International Classification of Diseases-10 (ICD-10) is a familiar topic to providers generally and, in particular, to the JNIS readership.1–3 Currently, ICD-9 codes are used nationally to report medical diagnoses and inpatient procedures. These codes are now 30 years old, and for a variety of stated reasons have been slated for evolution to ICD-10. In previous manuscripts, we have explored planned implementation of ICD-10 and delays affecting this process. There has been extensive press coverage of the historic opportunity this evolution represents, and the US government's recent failure to fix the sustainable growth rate (SGR) formula (the means by which Medicare expenses are controlled so as not to outstrip gross domestic product growth). On April 1, 2014, another temporary SGR fix, a 1 year patch, was signed into law. As part of that law, ICD-10 implementation and adoption was pushed back by at least 1 year.4 This extension has elicited significant negative reactions from proponents of ICD-10, including criticism that this delay further increases healthcare costs.5


ICD-10 and SGR have been the major regulations impacting physicians in 2014.1–3 ,6–8 ICD-10, which was inconspicuously included in a provision in reference to diagnosis and procedure codes, was based on final ruling from the Department of Health and Human Services (HHS) of January 2009 to convert from ICD-9 to ICD-10 on October 1, 2013.9 ,10 Since then, numerous manuscripts have been written along with advocacy efforts by various organizations to indefinitely delay the implementation of ICD-10-CM until the appropriate necessity is proven and the consequences, both intended and unintended, are established.1–3 ,6–8 ,11 Health Affairs published a manuscript illustrating the seemingly obvious point that ICD-10-CM conversion will be expensive, arduous, disruptive, and of limited direct clinical benefit. Others have explicitly described negative but preventable consequences of ICD-10 seemingly being implemented without evidence of necessity.1–3 ,11 In the era of evidence based medicine and comparative effectiveness research, we find it curious that HHS would implement something based on ideas provided predominantly by non-medical professionals without proven benefit of improving patient care, particularly in the current climate of escalating healthcare costs and heightened attention to overall medical expenses.

The original implementation date of October 1, 2013, was extended by HHS in the latter half of 2012 to initially October 1, 2014.10 ,12 The present discussion revolves around the most recent extension on April 1, 2014, which was embedded in a temporary fix of SGR for 1 year and has been postponed until at least October 1, 2015.5

Opponents of ICD-10 sometimes compare it with the Health Insurance Portability and Accountability Act (HIPAA) rule in light of its many unintended consequences and extensive cost.3 ICD-10 is estimated to cost between US$83 292 to $2.7 million for each practice, based on practice size.13 ,14 In addition, cash flow disruptions may range from $50 000 for very small practices to between $1 million and $15 million for mid size and large practices.13 ,14 Perhaps most impressive, the Center for Medicare and Medicaid Service (CMS) has conceded on this issue of cash flow disruptions with implementation of ICD-10.15–17

While the legislation postponing ICD-10 implementation has been celebrated by many physician groups, there has also been opposition. While enthusiastic about the SGR reduction not taking affect, we and many physician organizations were disappointed by the failure to achieve a permanent patch. On the question of the delayed implementation of ICD-10, many physicians were quite sanguine. However, that opinion is not uniform.

ICD-10 supporters include CMS, information technology professionals, and a variety of hospital organizations. They argue that ICD-10 will improve operational processes across the healthcare industry by using updated terminology and disease classifications. The hope is that these changes will increase the flexibility for future updates with enhancement of code accuracy. Further, proponents also argue that ICD-10 conversion may support refined reimbursement models and streamline payment operations providing more detailed data and opportunities to develop and implement new pricing and reimbursement structures. Essentially, this may also provide payers, program integrity contracts, and oversight agencies with opportunities for more effective identification and subsequent investigation of potential waste, fraud, or abuse.16 ,18–24

Some proponents of moving forward with the ICD-10 system have criticized the SGR fix and estimate that the price tag for a previous 1 year delay in implementing ICD-10 was between $1 billion and $6.6 billion. It is assumed that costs of the new delay will be at least as great.5 They note that these costs are in addition to the billions already spent by providers, payers, electronic health records vendors, and others to prepare for the conversion. The authors believe that the most compelling rationale for frustration with delay is expressed by the American Health Information Management Association. They noted that hospitals, healthcare systems, third party payers, and physicians’ offices have made substantial investments to be ready for the October 1, 2014, deadline and the transition to ICD-10. The implication is that there is significant cost incurred by delaying for an additional year.25–27

History and recent background

Briefly, the history of ICD dates back to the 18th century when a French physician published a classification system for diseases.1 ,2 Amazingly, in an era with no computers, there were 10 major types of diseases with 2400 individual diagnosis. In the late 19th century, the International List of Causes of Death (ILCD) was adopted in the USA. The ILCD classifications for mortality reporting were officially published approximately every 10 years from 1900 until the Second World War. In 1948, the WHO assumed management of the ILCD and expanded it to include morbidity coding. It was titled the International Classification of Diseases at that time, marking a new era in global healthcare statistics, and undergoing several revisions since. The International Conference for the Ninth Revision of the ICD met in Geneva in 1975, and produced the current ICD-9 that we use. The WHO determined at that gathering to space future revisions to greater than 10 year intervals, and rework the structure of ICD-9 completely to provide a stable classification system with greater longevity. ICD-10 was already a work in progress then, and was originally published in 1992 as a classification of mental and behavioral disorders, including clinical descriptions and diagnostic guidelines, and has been in use in many countries for over a decade.

The version we use in the USA is considerably more finely grained, having been modified over several years to be more relevant to the US population through efforts of the Centers for Disease Control and CMS. A lag almost always exists between formulation of policy and implementation, and ICD-10 is no exception. It took until 2009 before a Department of HHS ruling required that healthcare participants convert from using ICD-9 to ICD-10 on October 1, 2013.10 In our October 2011 JNIS manuscript, ‘Ready or not! Here Comes ICD-10’, we called for a delay in the implementation of ICD-10.2 In February 2012, HHS ruled that the ICD-10 implementation deadline would be postponed until October 1, 2014.12 In a year that saw unprecedented enthusiasm for the possibility of a permanent fix to the deeply unpopular SGR formula, Congress came up short and provided another temporary patch on April 1, 2014. On April 1, 2014, President Obama signed the ‘Protecting access to Medicare Act of 2014,’ HR 4302, in which the main point was a 1 year fix for the SGR until April 2015.4

Relationship of the ICD-9 to ICD-10 system

The clinical modification of ICD-9 was developed by the National Center for Health Statistics and put into use in the USA in 1979 as the ICD-9-CM system. In 1983, the Inpatient Prospective Payment System was adopted, and portions of the ICD-9-CM were used for assigning cases to diagnoses related groups. The system has been updated periodically. Responsibility for maintenance of the ICD-9-CM is under the auspices of the CMS.

ICD-10-CM has the same type of basic structure as ICD-9-CM. All codes have the same first three digits, with each subsequent character providing greater specificity. ICD-10-CM is alphanumeric with up to seven digits per code. We refer interested readers to our previous manuscript detailing the differences between ICD-9-CM and ICD-10-CM.1–3

Briefly, there are multiple issues in relation to the transition from ICD-9 to ICD-10. Essentially, it has been mandated that switching from ICD-9 to ICD-10 involves a change from 14 000 codes to between 69 000 and over 140 000 codes, a whopping increase of up to 712%, creating enormous complexities, confusion, and expenses. Some of the findings related to code mapping found that while 60% of the ICD-9 codes translated to ICD-10 codes reasonably, 36% of the ICD-9 codes were ‘convoluted’ with entangled and non-reciprocal mappings, and 1% of the ICD-9 codes had no corresponding codes under ICD-10.28 ,29 Fortunately, neurointerventional is not likely to be significantly affected. Table 1 shows subarachnoid hemorrhage with conversion of ICD-9 to ICD-10. In a previous manuscript, we illustrated a variety of other neurointerventional codes and related difficulties with conversion.2

Table 1

Illustration of subarachnoid hemorrhage with conversion of ICD-9 to ICD-10

Box 1 illustrates some of the codes highlighted by the media regarding ICD-10 conversion in modern healthcare.30

Box 1

ICD-10 codes—crazy or funny?

  • Codes for injuries in opera houses, art galleries, squash courts, and nine locations in and around a mobile home, from the bathroom to the bedroom.

  • Medical problems related to a duck, macaw, parrot, goose, turkey, or chicken are associated with nine codes for each animal.

  • Codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting (but not shopping)

  • Other interesting codes:

    • R46.1 is ‘bizarre personal appearance’

    • R46.0 is ‘very low level of personal hygiene’

    • W22.02XA, ‘walked into lamppost, initial encounter’

    • W22.02XD, ‘walked into lamppost, subsequent encounter’

    • V91.07XA, ‘burn due to water-skis on fire’

Source: Mathews.30


While there are proponents and those that disagree with the widespread implementation of ICD-10, there is no argument with the fact that it will be an expensive proposition. Health systems, which are facing unprecedented pressures including but not limited to conversion to an electronic medical record, accountable care, and diminishing reimbursements, in good faith began to invest in the conversion to ICD-10. Readers should remember that it was only a half a year from the go live date when it was postponed.

The system itself has challenges. The level of detail embedded in ICD-10 requires extensive research from billers and coders (and physicians) to be familiar with coding options. The cost of implementation is high and is coming at a time when providers and hospital systems are struggling under the weight of regulatory burden. The SGR patch brought a further reprieve for those unhappy about moving to ICD-10 (including many physicians and several of the authors of this review). Other constituents affected (such as health information management organizations) are less sanguine, explaining that their members invested tremendous resources in anticipation of making the conversion and now feel like they are holding the bag.

Whatever our personal opinions, as healthcare providers it is of crucial importance that we focus on staying informed and current about ICD-10 developments, since the implementation of this classification system is inevitable. Healthcare evolution is an exciting process, and one that we need to be intimately involved in to ensure its relevance to modern care.


The authors would like to thank Irina Badayan for her assistance with the manuscript.



  • Contributors JAH and LM wrote the original draft. TLM, GNN, RO, KAS and EZ all reviewed and made substantial editorial suggestions many of which were incorporated into the manuscript.

  • Competing interests None.

  • Provenance and peer review Commissioned; not externally peer reviewed.

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