ICD-9 or ICD-10: What Is the Point?

Regardless of which version you are considering, the International Classification of Diseases, Clinical Modification (ICD-CM) is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all healthcare settings. ICD-CM is based on ICD, the statistical classification of diseases published by the World Health Organization.

Unfortunately, to most providers and coders in the United States, the ICD-CM code set has been reduced simply to a means of reimbursement. That narrow thinking may completely miss the point.

One key component of any medical document is accurate and complete communication: document (or report) the most appropriate specificity about the patient’s condition. This assists in the treatment of patient care, is used for future treatment plans, and, once that clinical information is translated into data, becomes the database from which healthcare is monitored and measured.

Somewhere along the line, though, this key step has been reduced to a shortcut that has created a database that will eventually shortchange the provider and the patient. Oncologists will often describe the complexity of their patients: the challenging medical decisions required of them each day because of the diverse clinical demographics of their patients, and the frequent but lengthy visits required to manage the myriad of side effects, complications, and even chronic medical conditions they inherit as they become a primary point of medical contact.

The data tell a different story. The database of diagnosis codes would imply that patients with cancer are rarely seen for anything but a primary condition. Multiple high-level evaluation and management (E/M) services are required to manage cancer when the specific site is unreported. The average oncology claim indicates “lung cancer,” “breast cancer,” or perhaps “anemia.” The database would imply that less than a handful of patients have neoplasm-related pain, anemia resulting from chemotherapy, or even long-term drug use.

As the industry debates the value of implementing the ICD-CM, Tenth Revision (ICD-10-CM), please take the time to determine the value of the data from your own office in comparison to the real story shared by the clinicians in your office. Run a frequency report on the diagnosis codes reported within the past 6 months. You have been working on clinical documentation improvement for months, but everyone is waiting for the magic “go live” date for ICD-10-CM to test the value of that project. Why wait?

Increased specificity in the reporting process is needed now, is available now, and will generate a more accurate database from which the new formula for physician reimbursement will be created. If we are to have any hope of being appropriately reimbursed in the future when we are under a case mix, pay-for-performance, or even quality outcome measurement system, we need accurate data.

Look at that frequency report. Based only on the data (which is what the payers see), how many patients in your practice were seen to manage their chemotherapy- related or neoplasm-related pain? How many were seen for the well-known side effects: nausea, vomiting, fatigue, or neuropathy? How many developed systemic conditions as a result of the treatment and/or the malignancy? Drill down on anemia—how many patients have anemia as a result of chemotherapy versus anemia as a stand-alone condition? If you had to project the likelihood of a secondary malignancy or the recurrence of a malignancy from any given primary site, could you, from the data you have in your practice?

Unfortunately, most could not. We have developed a habit of linking E/M services to the most generic cancer code available. We endure payer audits focused on our levels of E/M services—focused on our use of modifier 25—and yet we continue to submit generic, unspecified diagnosis codes that will continue to raise an audit alert. Imaging studies are ordered for the primary cancer, despite the reality that the magnetic resonance imaging (MRI) really was not about the pancreatic cancer, but about the patient’s complaints of persistent headaches and blurred vision. The MRI was to evaluate for metastases, but the “reason for exam” did not state that. And we will continue to be audited for our “excessive orders.” We will continue to see limits placed on the imaging studies we order, because the data do not support the medical necessity of the current process.

ICD-10-CM may be the best catalyst we have had in decades to clean up the reporting process related to the treatment of this complex patient population. If the specific location of the malignancy is known, report it. When the patient is seen and resources are used to manage the side effects, report them. If resources are expended to evaluate scans, compare treatment plans, and manage the referrals and opinions from multiple providers, translate that paragraph in the medical record into the appropriate diagnosis codes now. The codes exist today.

Do not delay the implementation of ICD-10-CM content in your practice. Do not focus on the code set; focus on the primary benefit of that code set. You will position your practice to be the one with the data when the new reimbursement model is defined and implemented.

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