Background: HHS requirements, ICD-10-CM will become a standard



A specific
healthcare data standard that applies to population health management are the
ICD-9/10 diagnosis codes. The International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) is the United States health system’s
adaptation of the international ICD-9 standard list of six-character
alphanumeric codes.1 ICD-9-CM
contains a list of codes corresponding to diagnoses and procedures recorded in
conjunction with hospital care in the United States. These codes are primarily
entered onto a patient’s electronic health record and is the most universally
applied classification system for coding diagnoses, reasons for healthcare
encounters, health status, and external causes of injury. In 1946, the United
Nations delegated responsibility for the International Statistical
Classification of Diseases and Related Health Problems (ICD) to the World
Health Organization (WHO), after the concept was first introduced by French
physician J. Bertillon back in 1893.

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1 WHO conducts and issues periodical revisions of the ICD and in the
late 1970s, the ICD 9th revision was designed, and by the 1980s
adopted around the world.

To make the
application of ICD-9 appropriate to the American healthcare settings, the
National Center for Health Statistics (NCHS) and the Council on Clinical
Classifications jointly created ICD-9-CM.

1 Since the late 1970s, ICD-9-CM has been the required standard for
billing and clinical purposes by the most payers in the United States,
including the Centers for Medicare and Medicaid Services (CMS). WHO leaders
realized that even larger classification changes would need to be implemented
in the near future therefore, the development of the 10th revision
of ICD was initiated. Published in 1990, the ICD-10 included significantly more
categories and over 138,000 more codes that ICD-9, tracking a significant
number of new diagnoses. 2
The improvements from the ICD-9-CM to the ICD-10-CM include diagnosis and symptom
combinations that reduce the number of codes required to describe a certain
medical condition, additional information relevant to the description of
managed care and ambulatory encounters, and greater specificity in codes.

In 2014, the US
Department of Health and Human Services (HHS) published a final rule requiring
the use of ICD-10-CM to replace ICD-9-CM in the Health Insurance Portability
and Accountability Act (HIPAA) electronic transaction standards. 2 In the United States
specifically, ICD-10 consists of two parts: ICD-10-CM for diagnosis coding and
ICD-10-PCS (Procedure Coding System) for inpatient procedure coding. According
to the HHS requirements, ICD-10-CM will become a standard for all US healthcare
settings whereas ICD-10-PCS will be required in inpatient settings only.

Significance & Current

ICD-9/10 is important
to population health management because it helps to achieve the Institute of
Healthcare Improvement’s Triple Aim: improving the quality of patient care,
improving the health of populations, and reducing the per capita cost of health
care. Specifically, with the development of ICD-10, health care coding around
the world has been improved and modified, leading to new diagnostic terminology
and a coding system that more accurately represents specific diagnosis and
procedure information.

Quality of Patient Care: By providing
more specific, higher-quality data, providers are able to create more finely
tuned protocols, resulting in better patient experiences and improved health
outcomes. ICD-9/10 codes, which are assigned to virtually all inpatient
discharges, could provide a readily available surveillance system capable of
detecting a variety of adverse events.3
Tracking individual adverse event rates is essential for hospitals and health
care systems as they improve patient safety and quality. Adverse events are significant and
common sources of harm to inpatients. Adverse events in the hospital setting
carry with them significant patient morbidity and increased health care costs.

There is increasing interest in improved methods of adverse event surveillance
as payers of medical care move towards systems that reward high quality and
avoid paying for harmful patient-outcomes. 3

 A 2008 study was performed using ICD-9-CM
diagnosis codes in hospital claims data, from several Utah and Missouri state
hospital systems, to detect adverse events in patient safety surveillance.  Samples were drawn from two distinct patient
groups: 7,070 inpatients from all acute care hospitals in Utah and 6,895
surgical inpatients from selected hospitals in Missouri. 4 The objective of the study was to determine the positive
predictive value of selected ICD-9-CM codes (flagged codes) in identifying
inpatient adverse events and adverse events causing admission to the hospital. Researchers
used structured chart review and identified all adverse events and whether a
flagged ICD-9-CM code represented an adverse event. Among all inpatients, 38
percent of flagged codes represented adverse events. 4 Overall, flagged codes were consistently more likely to
indicate adverse events in surgical inpatients that in all inpatient types but
given this, ICD-9-CM codes are best suited to targeted adverse event

Improving the Health of Populations: Creating
a more internationally consistent and interchangeable coding system has
improved tracking patient care and identifying disease patterns that may affect
patient outcomes. ICD-9/10 diagnosis codes recorded in Electronic Health
Records (EHRs) offer potential for population health surveillance, which can
ultimately improve population health outcomes at the local, state, national,
and global level. By efficiently collecting and documenting data in the form
that can be shared across multiple health care organizations and leveraged for
quality improvement and prevention activities, researchers can more readily
predict trends in health care and provide greater information on disease
prevention and possible errors in care.5

NCHS, the federal agency responsible
for use of the ICD-10 in the United States, has developed a clinical
modification of the classification for morbidity purposes. NCHS, in partnership with the CDC, use ICD-10 to code and
classify mortality data from death certificates from state vital statistics
offices, having replaced ICD-9 for this purpose as of January 1999.5 This data has been gathered from the inpatient and
outpatient records, physician offices, and most NCHS surveys. For example, The
CDC Influenza Division collects, compiles, and analyzes information on
influenza activity year-round in the United States and produces ‘FluView’, a
weekly influenza surveillance report. 6 The US
influenza surveillance system provides information in five categories collected
from eight data sources, one being mortality data from NCHS’ mortality
surveillance system. 6 NCHS identifies pneumonia and
influenza deaths based on ICD-10 multiple cause of death codes. NCHS
surveillance data are aggregated by the week of death occurrence. Based on the aggregated
data, pneumonia and influenza percentages are released two weeks after the week
of death to allow for collection of enough data to produce a stable pneumonia
and influenza percentage. 6 The percentage of deaths caused by
pneumonia and influenza are continuously revised and may increase or decrease
as new and updated death certificate data are received from states by NCHS. The
reported information answers the questions of where, when, and what influenza
viruses are circulating. It can be used to determine if influenza activity is
increasing or decreasing. 6

The CDC can use these percentages as a
basis for studying the seasonal prevalence of the flu virus and sending out
geographic-centric recommendations encouraging residents in flu-stricken areas to
get their flu shots. This form of surveillance, that leverages the benefits of
the ICD-9/10 coding system, can really make an impact on delivering substantial
health information to high-impact communities whether local, state, national or

Reducing the Per Capita Cost of Healthcare:
The new ICD-10 codes include greater detail, requiring providers to incorporate
detailed descriptions of body parts and describe devices, methodology, and
procedures used in treatment. In
addition, ICD-10 coding system allows providers to specify whether a condition
is acute or chronic and any external factors that are related to the condition
and whether the patient is receiving initial or first treatment or is receiving
ongoing/routine care. 1 There are many benefits of the new
codes and the greater detail they capture apply primarily to the areas of
public or private health. One benefit is better information for designing
payment systems and processing claims data. For worker’s compensation, one
advantage of the new codes is that they allow providers to more accurately
specify comorbidities or medical conditions that exist simultaneously but often
independently of one another.

7 The common co-morbidities
that are often seen in workers compensation claims include hypertension,
respiratory diseases, obesity, and diabetes. 7 These
conditions may rarely effect on-the-job performance and, they are typically not
covered as a workplace injury or illness. As a result, many employers are not
aware of how these conditions can affect the duration and ultimate costs of a
workers’ compensation claim. For example, hypertension can contribute to delays
in needed surgery and diabetes can slow the healing of a cut or wound.

Recognizing when comorbidities are present is a critical first step in
implementing proactive claims and managed care strategies that can manage and
reduce the impact of comorbidities and ultimately control individual healthcare
costs. 7

The shift from ICD-9 to ICD-10 codes
will benefit healthcare providers in the form of more accurate payments for new
procedures, fewer improper reimbursement claims, and greater efficiency in the
billing and reimbursement process.

7 The increased
specificity of the ICD-10 will help in reduced number of claims being
investigated or rejected due to insufficient information. Not to mention, fewer
rejected claims will reduce the amount of rework for providers leading to an efficient
reimbursement process which in turn, will lower the provider administrative
costs. A reduced claims cycle coupled with lowered administrative costs will
help providers shift the excess resources in improving patient care. 7

The fact is that the US spends more on
healthcare than other high-income nations, but has a lower life expectancy. The
analysis shows that in the US, which spent an average of $9,086 per person
annually, life expectancy was 78.8 years.8 In
order to reduce costs and improve the quality of care, the US healthcare system
is moving from fee-for-service to value based care. The increased specificity
of ICD-10 codes will make it easier to compare reported codes with clinical
documentation, check for consistency between diagnosis and procedure codes, and
check for illogical combinations of diagnoses. 7 The
use of ICD-10-CM and ICD-10-PCS can help reduce the opportunities for fraud and
improve fraud detection capabilities. 7 Fewer
grey areas in coding will make it more difficult for providers to hide behind
ambiguities in code descriptions or rules. This can significantly reduce costs
for patients, payers, and hospitals.