Loyola University Chicago School of Law, JD 2019
In October 2015, the tenth revision of the International Classification of Diseases (ICD-10) was implemented in the United States. Three years earlier, however, ICD had already begun beta testing for its eleventh revision (ICD-11). The ICD-10 implementation came after repeated delays and substantial requirements for healthcare organizations to reach compliance with the new codes. The United States trudged through training and compliance struggles as it transitioned to ICD-10. The threat of ICD-11’s release in 2018 promises to have drastic and far-reaching effects on the compliance actions of healthcare organizations.
ICD is the standard in clinical and research settings for reporting of diseases and health conditions. The World Health Organization (WHO) identifies ICD as “the foundation for the identification of health trends and statistics globally.” WHO recognizes multiple purposes for ICD, including the monitoring, observation, and tracking of health conditions, but its most recognized use is in healthcare provider offices. ICD codes are used throughout the healthcare industry to accurately record diseases and diagnoses in health records, and to assist in medical reimbursement between providers and payors.
ICD-10 was implemented in the United States on October 1, 2015 after significant delays. WHO began preparing the ICD-11 many years prior to that implementation, and ICD-11 is slated to be released in June 2018.
Will the ICD-10 growing pains repeat themselves with ICD-11?
ICD-10 faced years of delays before it was implemented in the United States. Those delays were the result of both CMS actions, legislation from Washington, DC, and stifled momentum in the transition from ICD-9.
The transition from the ninth revision (ICD-9) to ICD-10 was substantial because of major changes in the code sets. ICD-10 contains nearly nineteen times the number of procedure codes as ICD-9 (from 3,824 to 71,924), and it codified nearly five times as many diagnosis codes (14,025 to 69,823). The categories of the code also changed from numeric to alphanumeric. Further, some chapters were re-ordered, titles re-named, and some conditions grouped differently.
In the face of these extreme delays, many in the healthcare industry pushed for the United States to skip ICD-10 and wait for the forthcoming ICD-11. The American Health Information Management Association (AHIMA) outlined the opposing viewpoints to that plan in 2012, noting the cost and dangers of retaining the outdated ICD-9 revisions and the potential risk of making the transition to ICD-11 even more difficult. Use of the outdated code purported to have an increasingly “adverse impact on the value of healthcare data, including the accuracy of decisions based on faulty or imprecise data.”
Compliance from ICD-9 to ICD-10
The major changes from ICD-9 to ICD-10 demanded focused compliance efforts. In an interview just after the United States’ ICD-10 implementation, George B. Breen, Member of Epstein Becker & Green and Chair of the National Health Care and Life Sciences Steering Committee spoke to Xtelligent Media about the seriousness of ICD-10 compliance. “The impact of ICD-10 needs to be looked at from a compliance perspective, from a perspective of where the government will be looking now that ICD-10 is here.” Breen stated that the use of ICD-10 raised “hot issues” of medical necessity and reasonableness for the government. He urged compliance professionals to take the change very seriously given the propensity of ICD-10 to allow the government a closer look at provider claims and records.
Breen further noted that the increased level of specificity required by ICD-10 codes created a higher expectation for supporting medical documentation. Then, and now, compliance efforts in provider offices must be effective in a way to support the claims that are submitted. Breen stated:
“The reality is most people are billing and coding and documenting in a fashion they believe absolutely justifies the bills. It’s another reminder for people to consider that this is an area the government has been looking at for a long time, it’s laser-focused on these issues. This gives the government another opportunity to examine these issues, which is why it ought to be significant.”
A history of delays is likely to repeat itself
As news of forthcoming diagnosis codes spreads, the industry confidently believes that actual implementation of ICD-11 will see the same trend in delays as ICD-10. “It’s one all-too-familiar to health and technology professionals who lived through the ICD-10 transition. That particular implementation was fraught with delays – and it took more than two decades from the time WHO finalized ICD-10 in 1992 to the dreaded U.S. deadline of October 1, 2015.”
AHIMA predicts that the threat of ICD-11 is less than imminent. “Adoption of ICD-11. . . doesn’t mean it can be immediately implemented by the US. It will take several years of review, and perhaps some US modifications for US-specific data needs, before it will be ready for implementation in the US.”
Compliance with ICD-11 may not be as difficult this time around
However, healthcare industry billing professionals don’t expect the painful transition of ICD-9 to ICD-10 to repeat itself with ICD-11. “ICD-11 builds upon ICD-10, so it should not be as large of an adjustment as ICD-10 was.” With proposed changes only in descriptions and definitions, a semantic network of words and terms, categorical definitions by logical operational rules, and links to existing terminologies, the changes this time around look to be less quantitative and more focused on quality. The indication is that ICD-11 “will make usage of the coding system more integrative and user friendly. . . For medical providers who are still struggling with the limitations of the ICD-10 system, the arrival of ICD-11 is greatly anticipated.”
With a few adjustments, implementation of ICD-11 should be a smooth transition for any organization that took compliance with ICD-10 seriously. There is no profound foundational change like ICD-10 brought from ICD-9. The most relevant compliance issues with a change in ICD revisions will look at the organizations ability to adapt:
- Ensure the most accurate coding is in place for the current system so that the transition to ICD-11 is not working from any ICD-9 remnants.
- Employ a holistic approach to compliance.
- Invest in resources, including consultants and ICD-11 experts, to ensure coding is compliant.
- Budget for the training now, while implementation is still pending.
- Identify compliance gaps and identify plans to close such gaps.
- Compare current regulation to current performance.
While news of new ICD-11 codes and pending implementation continues to spread, the healthcare industry should cautiously prepare. Billing, coding, and provider organizations can take steps now to ease the transition. If history repeats itself, efforts to ensure continued ICD-10 compliance, and preparation for known changes, appear to be the best tactics as we wait for the United States implementation of ICD-11. Organizations that have yet to reach full ICD-10 compliance are likely to face significant struggles with ICD-11 and should not rely on predictions of delays to direct their compliance efforts.