Today is going to be the last day looking at other people’s “Top Health IT Lists” since tomorrow I think I’ll create my own Top 10 Health IT 2011 List and then for the New Years I’ll see about doing a Top 10 Health IT in 2012 list. However, today let’s look at something that will likely make the Top 10 2012 Health IT issues: ICD-10. Government Health IT recently wrote an article what they call the Top 5 ICD-10 Pitfalls.

1. Reporting: I’m sure that many think that ICD-10 is just going to happen and be fine. They’ll assume that their reports are just going to work with ICD-10 since they worked with ICD-9. Don’t be so sure. Test the reports so you know one way or another. Diving a little deeper beforehand is a lot better than learning about the problems after.

2. Overlooking impacted areas: Much like an EHR implementation, don’t forget the other people that are affected by ICD-10. Involve everyone in the process so that they can share their concerns so they can be addressed. Plus, by having them involved you’ll get much better buy in from the staff.

3. Teaching old dogs new tricks: ICD-10 is a different beast and will require significant training even if you have an expert ICD-9 coder with years of experience. Don’t underestimate the cost to train your coders on ICD-10.

4. Preparing for impact on productivity: The article mentions Canada’s loss of productivity during their implementation of ICD-10. Do we think we’re going to be any different? Remember also that productivity loss can come in a lot of different places (which is kind of a repeat of number 2 above).

5. Communicating with IT vendors: It’s one thing to trust that your EHR and other health IT vendors are prepared to deal with ICD-10. It’s another to blindly follow whatever you’re being told. Remember at the end of the day it’s your organization that will suffer if your health IT vendor is not ready. I like to use the phrase, trust but verify.

Be sure to read the rest of my Health IT Top 10 as they’re posted.

The Wall Street Journal put out an interesting article about the switch from ICD-9 coding to ICD-10. The title mocks the ICD-10 codes, Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way”, and the subtitle is funny as well, “New Medical-Billing System Provides Precision; Nine Codes for Macaw Mishaps”

I must admit that I’m not very well steeped in the history of ICD-9 and ICD-10. Nor am I that familiar with the process that was used for creating the voluminous ICD-10 coding system. I’m more of a practical person and so I’ve been more interested in EHR’s ICD-10 preparedness and the timeline for ICD-10 implementation. Seems like we won’t have much choice.

I guess I should have known that going from 18,000 codes (which doctors can’t even stay up with as is) to 140,000 codes would offer some crazy and hilarious codes. Here’s some examples from the article linked above:

There are 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.

And the appropriate follow up question from a family physician, “Really? Bathroom versus bedroom? What difference does it make?”

Some other interesting codes mentioned in the article:
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”

There are codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting—but not while shopping. There are codes for injuries from birds such as: a duck, macaw, parrot, goose, turkey or chicken. I’d hate for my doctor to choose the “bitten by turtle” versus “struck by turtle” code. My insurance company might not reimburse the second.

Do people know of any other off the wall ICD-10 codes?

While this has me a little concerned to see ICD-10 in action, hopefully it will give all of you a good laugh going into the weekend. I can’t say I saw a code for any sort of Friday inefficiency, but there probably should be.

Chuck Podesta is Fletcher Allen Health Care’s chief information officer.

ICD-10 would not be so daunting if the deadline was not occurring during the rush to get EHRs for meaningful use. Add in value-based purchasing, bundled payments and transitioning to ACOs, and you can see why many CIOs are retiring early or migrating to the vendor or consulting world. We are just over two years away from the October 2013 deadline, and there is much work to be done. ICD-10 contains 68,000 codes, as opposed to the 13,000 currently used in the ICD-9 world. There is a code for every condition that exists on the planet.

The revenue cycle system, which includes registration, HIM and billing/AR, will be the lynch pin to ICD-10 readiness. Having a solid vendor partner and a strong product is key to a successful transition. Many solution providers – like GE Healthcare, who recently launched the 5.0 version of their Centricity Business product – are updating their systems to better comply with ICD-10. GE Healthcare also allows existing Centricity Business customers to retrofit the new ICD-10 functions to the 4.6 version of the product. Strong vendor partners take the burden off you by being ahead of the game and delivering the appropriate technology in time so you are not racing to the finish line.

By now, you should have at least a steering committee in place. Your IT shop should have completed an inventory of all applications that are impacted by ICD-10, including reporting systems. You will be surprised by the number of applications, even if you have taken the one-vendor approach for most of your IT needs. You will need to contact all affected application vendors to see what the plans are for ICD-10 compliance. Most likely, upgrades will be required that will need to be scheduled.

Training of coders will be critical, along with implementing clinical documentation improvement programs. Documentation improvement programs are difficult to implement and will be viewed by providers as more work on top of an already busy schedule. New technologies such as computer-assisted coding will definitely help, but success will be a combination of process improvements and technology.

Lastly, remember that the deadline is for Medicare and Medicaid patients only. Unless the rest of the payer industry follows the same deadline (highly unlikely), you will need to run both ICD-9 and ICD-10 systems.

I guess kind of like they just had Shark Week on TV, this week on EMR and HIPAA has been ICD-10 week. So far I’ve covered EMR vendors ICD-10 planning, moving to ICD-10 and bridging from ICD-9 to ICD-10.

In response to my previous ICD-10 posts, Gordon Fenton provided this interesting insight about the UK’s experience with ICD-10.

Over in the UK we already use the ICD10 along side the OPCS code to generate our HRG’s which is the currenvy that commissioners and providers use in the billing process.

While I am based on the commissioner side I know that our providers employ coders whose specific job is to translate Doctors notes into ICD and OPCS codes.

The main challenge will be in varifying and validating the codes being applied by providers, the IT is just a small issue. It will be very easy for providers to inadvertantly apply the wrong code simply by the fact that there are so many.

You could do a lot worse than look at the UK model for guidance on how we deal with it

I’m always interested to learn from what other countries are doing with technology and EMR. I’d love to learn more about UK provider’s experience with ICD-10 and how we can improve the eventual ICD-10 implementations in the US.

In response to my previous EMR and ICD-10 posts, an EMR vendor recently sent me how they plan to address the transition from ICD-9 to ICD-10. Here’s their plan:

1. We are going to have both the ICD-9 and ICD-10 codes reside in the same file in our application. This will allow the charge entry people to enter either code. There will be a field in the ICD-9 that will map to a single ICD-10.
2. We will provide a report to each doctor showing them the frequency of the ICD-9 codes they used over a period of time that they can specify. This report will show the available ICD-10 codes. The doctor can study it, start to change, or ignore it.
3. The staff can opt to let the software map one ICD-10 to the ICD-9 or manually enter the code of their choice.
4. Our electronic claims software will have a flag per insurance carrier indicating whether or not it will accept ICD-10. For those that will, we will map the ICD-9 to the 10 and send that code. If no map identified, we will generate an error edit.
5. At some point down the road, we will use the information collected from billing to update the doctor’s preferred list of dx codes in the EMR.
6. We will have to augment customized programs at each client site that may be doing reports based on ICD-9.

The push to ICD-10 is rapidly approaching. That’s why I was interested to know how EMR vendors were going to get the ICD-10 code list. However, there are going to be a lot of other nuances for EMR vendors to move from ICD-9 to ICD-10.

The following is a short description of some real data around the move from ICD-9 to ICD-10. It’s from a newsletter sent out by ArcSys including some interesting data from a real clinic. It’s going to be interesting to make the transition to ICD-10 along with all the fun things happening around Meaningful Use.

On October 1, 2013, all claims processing needs to be transitioned to the new ICD-10. As you can well anticipate, this will be a major change for the healthcare industry. As a practice, your biggest challenge will be the re-education of the staff on what the new codes are and their associated nuances. Starting January 1, 2011, CMS will start to accept the 5010 claim definition which will allow for the transmission of the ICD-10 codes.

ArcSys will have the software tools in place to assist you in the transition. We can provide you with reports showing the frequency of which ICD-9 codes have been used by each provider. The major problem is that there is no one-to-one mapping—it is one-to-many for numerous codes.

As an example, from an internal medicine group, the number of times that a diagnosis related to diabetes over a one-year period produced the following part of a report:

250.00 703
250.01 81
250.02 145
250.03 27
250.30 1
250.40 16
250.43 2
250.51 1
250.60 43

If you look at the published mapping files as provided from the Centers for Medicare and Medicaid Services, you will find the following “simple” example:

25000 E119 10000
25001 E109 10000
25002 E119 10000
25003 E109 10000
25010 E1310 10000
25011 E1010 10000
25011 E1011 10000
25012 E1169 10000
25013 E1010 10000
25020 E1101 10000
25020 E1100 10000

Thus, ICD-9 code 250.00 maps to E11.9 (Type 2 diabetes mellitus without complications), and 250.20 maps to either E11.01 (type 2 diabetes mellitus with hyperosmolarity with coma) or E11.00 (type 2 diabetes mellitus with hyperosmolarity without nonkeototic hyperglycemic-hyperosmolar coma). Clearly, some “dusting off” of the old textbooks may be necessary to get a better understanding which code might make the most sense. (The 10000 number is a “computer number” that will be used to identify the degree of association between the the ICD-9 and ICD-10. It is far too-complex to describe in the space allotted here.)

I remember when I first started my job at a healthcare facility 5+ years ago, I ran into these codes they called ICD-9. Yes, this was all very foreign to me, but I learned quickly the meaning of ICD-9. I also learned quickly that the EMR vendor which had been selected (before I was there) didn’t provide a list of ICD-9 as part of their EMR software (they do now). They did provide an upload feature and so we exported a list out of our old PMS, cleaned them up a little and then uploaded them into the new EMR. Not a fun or effective process even that way.

Obviously, we’ve come a long way in five years. There are plenty of free lists of ICD-9 codes around the net that people can use, manipulate and add to their EMR software pretty easily.

However, I couldn’t help but wonder what solutions were being offered for EMR vendors planning for ICD-10. Yes, EMR vendors do have until October 1st, 2013 (which has been moved back a bunch of times so let me know if it’s been changed again) and so maybe EMR vendors aren’t concerned about it yet. Although, I’m guessing that many have already put a lot of thought into preparing for ICD-10.

My question for EMR vendors is, how are you planning to handle the ICD-10 codes? We’re talking about going from 14,315 diagnosis codes to 69,101 diagnosis codes. The National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS), AHIMA, the American Hospital Association, and 3M Health Information Systems have put together some General Equivalence Mappings (GEMs) that I believe try to do some mapping between ICD-9 and ICD-10. However, like translating a language there’s rarely a one to one match. With 4+ times as many codes there couldn’t be. So, certainly there’s the question of how you’re going to make the transition from ICD-9 to ICD-10 coding?

Although, at a simpler level, how are you planning to get the almost 70k ICD-10 codes in your system? Does anyone know of a database of these codes that’s available for EMR vendors? Is each EMR vendor going to try and create their own? What’s happening in this regard?

And maybe the answer is….ask us once we’re done dealing with stage 1 meaningful use. ICD-10 isn’t until stage 2 or stage 3 meaningful use.

I’ve been hearing a bit of discussion about ICD-10 really helping to solve some of the problems of interoperability. Their contention is basically that ICD-10 is more precise in its description of the diagnosis and so therefore the information that is coded using ICD-10 will then provide more specific codified information that can then be rather easily shared. If you haven’t read about the transition from ICD-9 to ICD-10, here’s a good article about the transition.

In theory, this is completely accurate. If everything went as outlined, we could really get a lot of interesting information for studies and for interoperability of health data out of our ICD-10 codes.

The problem is that in reality ICD-10 is just going to cause even more problems for sharing quality data. Not because we can’t share the data. That’s a topic for a different discussion. The problem is that we’re never going to achieve quality input of diagnosis codes.

I’m not a doctor and so I’m not going to give a specific example here. However, I think all we have to do is look at the current ICD-9 diagnosing patterns. I’ve seen from first hand experience that often a doctor gets stuck searching for the right ICD-9 code. Right or wrong, they end up picking a code that may not be exactly the right code for what they’ve seen. Maybe they choose NOW (Not Otherwise Specified) instead of the specific diagnosis that would be more appropriate. Add in the complexity of diagnosis requirements for getting the most out of your insurance billing and I don’t think anyone would disagree with the assertion that ICD-9 code entry is far from accurate.

I’m not trying to place blame. I believe this is a chronic problem in our health system that those in the trenches have known about for years. My point here is that if we can’t get the rather “simple” set of ICD-9 codes right, then how can we ever expect the much more complex set of ICD-10 codes right?

Everyone knows the common phrase of garbage data in produces garbage data out. When we’re talking about interoperability of EHR software, doctors really have to think if they want other people’s garbage in their system.

ICD-10 really could produce some awesome information if used properly. The challenge we face is producing systems that codify the data properly so we have meaningful interoperability of healthcare data.