ICD-10: The History of a Coding Set and Its Recent Impact on Neurosurgery

Stacey Snodgrass
John Kinna

ICD-10 is everywhere; it is the newest unavoidable implementation of regulations that impact the business processes of healthcare practices and institutions. Although it may be less onerous than Meaningful Use and PQRS regulations, it has had a large impact on the daily workflow of all neurosurgeons and their staff. Long gone are the days that we could rattle diagnosis codes from memory: 348.4, 724.2, 432.1, 742.0—everyone had their favorites.

The International Classification of Diseases (ICD) is rooted in international history. Attempts at systematic classification of diseases (through the study of deaths) dates as far back as the 1700s. More formal models came into existence in the late 1800s, and underwent interval revisions in the early 1900s. Recognition of international lists of diseases corresponding to international lists of causes of death came about in 1938. ICD-9 was introduced in the late 1970s, and in 1989, ICD-10 was borne. Ironically, it took 8 years to adopt a US version of ICD-10 and another 19 years until implementation (implementation was delayed three times over the course of four years). Final implementation came about on October 1, 2015.

ICD-10 has taken us from approximately 13,000 codes (using a five-digit structure) to more than 68,000 codes (using a seven-digit, alpha-numeric structure). And we aren’t finished yet. More codes are coming in 2016. Not only did CMS challenge our lives with the initial 68,000+, another 2,000 are being added later this year, with an additional 500 revisions coming to existing codes. The insanity! We now have a subset of codes for encounters with a duck. Or better yet, look up the expanded subset on spacecraft injuries. Thank goodness for the numerous smartphone applications and the ability to search by keyword or crosswalk.

CSNS and NERVES each conducted pre- and post-implementation surveys evaluating the impact of ICD-10 on neurosurgery. Data comparison spanned Jan–Sep 2015 (pre-implementation) to Oct–Dec 2015 (post-implementation) (Figure 1). Response was low, but the data showed that ICD-10 has had little impact on neurosurgery thus far. Respondents have reported decreased billing lag, increased average charges/day, essentially no change to days in AR, and a stable average of daily collections. Also reported was a decrease in percentage of denials.

We know that insufficient documentation has a direct impact on revenue. Nearly half of the codes created in ICD-10 provide for laterality, including specificities of late effects, injury, and sequelae, account for many of the other additions. And codes that more accurately described the seriousness of a condition have been deleted, i.e., neurogenic claudication is no longer viable language in ICD-10, which allows only the pertinent alternative of spinal stenosis. Learning ICD-10 subset expansions to ensure that the disease process is being described and dictated with the same verbiage as the code is not an easy process after years of utilizing other terms. However, being general or trying to get by with only documenting the basics is no longer sufficient to generate income for a practice. Codes should always be listed in the correct order to specify and preserve medical necessity, keeping in mind that documentation must support said coding.

In conclusion, it appears that our practices have seen little impact thus far. Our preliminary analysis was genuinely surprising. There was not a negative financial impact specific to claims processing with the implementation of ICD-10. The intense preparation of implementing ICD- 10 has likely increased our productivity and decreased the negative reimbursement consequences. What is not captured in most analysis is the expense that went into preparing for ICD- 10. Moving forward, it will behoove our practices’ bottom line to continue performing GAP analyses on key performance indicators. Keeping close watch on these reports will help ensure that any negative impacts to revenue streams are identified and addressed in a timely manner. We must also continue educating and staying current with updates. Neurosurgery is an ever-changing discipline, requiring that its professionals grow, adapt, and apply best practices.

Meanwhile, ICD-11 is under development now, and based on the World Health Organization’s timeline, it is expected to be finalized and released in 2017. Will we have another 27 years to prepare before implementation?

Article perspective is outpatient; does not include inpatient (ICD-10-PCS)