ICD-10: Overview of the Complexity

As hospitals begin preparations for ICD-10, it should be recognized that a parallel process will be taking place in the physician office setting. Fully integrated systems will produce the benefit of providing integrated education to physicians. In fragmented systems, physicians will be responsible for purchasing new IT systems, providing training for office billing staff and in many, many instances hiring new staff due to the anticipated attrition of professional billers as we transition to the new system.

What kind of awareness training should physicians receive now? The first step should be fostering awareness of the complexity of the system from a very high level to persuade physician leaders to begin preparations. In this article, I’ll focus on the diagnosis side of ICD-10.

Most healthcare leaders are aware that the number of diagnosis codes increases dramatically from ICD-9 to ICD-10. However, while the raw aggregate number of codes increases from approximately 13,500 to 70,000, the increase is not consistent across all categories.

Consider one localized group of fractures, those occurring in the femoral head and neck region. Under ICD-9 there are 12 available codes such as 820.02 Midcervical Femoral Neck Fracture, Closed or 820.11 Epiphyseal Fracture Transcervical, Open. These fractures are distinguished from peritrochanteric and shaft fractures.

In ICD-10-CM, Chapter XIX: Injury, poisoning and certain other consequences of external causes (including subchapter S00-T98, Injuries to the Hip and Thigh) are addressed in sections S70-S79. S72 is titled Fracture of Femur and is subdivided into S72.0 Fracture of the Neck of the Femur, S72.1 Pertrochanteric Fracture, S72.2 Subtrochanteric Fracture, S72.3 Fracture of the Shaft of the Femur, and so on.

In comparison to the 12 available codes for all femoral head and neck fractures in ICD-9, consider S72.0 Fracture of the Neck of the Femur. This appears to be a specific code, but under S72.0, using the appropriate additional digits S72.0xyz allows for markedly increased specificity.

There are, in fact, 576 subtypes of fracture within S72.0. There are 48 specific codes for Fracture of Unspecified Part of Neck of Femur, another 48 specific codes for Unspecified Intracapsular Fracture (of the femur), 96 codes for epiphyseal fractures (48 displaced, 48 undisplaced), 96 codes for mid-cervical fractures (again half displaced, half non-displaced), 96 codes for fractures of the base of the neck (same pattern), 48 codes for unspecified fractures of the head of the femur, 96 codes for articular fractures of the femoral head (displaced and non-displaced, and 48 codes for “other fractures of the head and neck of the femur.” If one considers all codes for femoral fractures from the proximal to distal aspects bilaterally, by my calculations there are 2,466 codes (though I may have missed a few).

The level of specificity required appears daunting. Can we expect coders currently using12 different codes to find the detail necessary to specify one of 576 codes? Further, do we expect orthopedic surgeons to provide all the necessary detail for this specificity? The challenge may not be as insurmountable as it initially appears.

ICD-10-CM diagnosis codes have 3-7 characters (compared to 3-5 in ICD-9) laid out in a specific format, with each character organized within any subchapter in a specific manner (see ICD-9-CM diagnoses/ICD-10-CM sidebar comparison).