Updated on: March 16, 2016

Leapfrog from ICD-9 to ICD-11: Providers Say No

Original story posted on: July 11, 2012

Jumping over ICD-10 and going instead to ICD-11 would be “like buying a bike but you don’t know how to ride one. If you don’t have the fundamentals on how to do that, I’m not sure how you could implement I-11.”


That’s how Nicholas Holmes, MD, chair of the department of surgery at Rady Children’s Hospital in San Diego, views the American Medical Association’s (AMA) July 19 announcement that its delegates had “adopted policy to evaluate ICD-11 as a possible alternative to replace ICD-9.” Dan Rode, vice president of policy and government relations for the American Health Information Management Association (AHIMA), agreed with Holmes, saying that moving to ICD-11 would be “a tremendous jump.”

Holmes and Rode, along with Bonnie Cassidy, vice president of HIM innovation for QuadraMed, joined the ICD10monitor’s July 10 edition of Talk Ten Tuesday (Leapfrog: 9 to 11. What’s Missing Here?) to discuss their views about the AMA’s proposal as well as industry activity as it awaits the final implementation date from the Centers for Medicare & Medicaid Services (CMS).

The Tuesday poll also asked listeners for their opinions of the AMA’s idea, and 72 percent responded that the healthcare industry should not leapfrog from ICD-9 to ICD-11 but implement ICD-10 first. But 12 percent did consider going to ICD-11 a good idea because “we don’t have enough time to implement ICD-10.” The remaining 13 percent and 3 percent, respectively, had no opinion or would opt for a fictitious version 10.5.

A July 19 AMA press release relies upon the same rationale the organization used when demanding that CMS delay implementation from October 1, 2013, to October 1, 2013. Specifically, Ardis Dee Hoven, M.D., the AMA’s president-elect, is quoted as saying, "ICD-10 coding will create unnecessary and significant financial and administrative burdens for physicians. It is critical to evaluate alternatives to ICD-9 that will make for a less cumbersome transition for physicians and allow physicians to focus on their primary priority—patient care.”

I-10 Lays the Foundation for Change

Rode pointed out that the I-10 structure must be in place before the industry moves to ICD-11. For example, there are five characters in ICD-9 codes and seven characters in ICD-10 codes, and that’s the number of characters needed for ICD-11. In addition to these and other technical changes to set up the transition, he says, “We need the kind of data that I-10 will provide to [allow us to] engage in the other programs desired by Congress and others, such as quality initiatives and value-based purchasing.”

Cassidy agrees, saying, “We must move forward incrementally” and gather the data needed. ”Better information also is needed on the coding side because ICD-9 is simply too outdated,” she says. She also believes that a focus on education and preparing the workforce is the key area to focus on right now, assuming that CMS finalizes its one-year implementation delay.

Education is, in fact, the very thing that physicians are receiving at Rady Children’s Hospital. Holmes indicated that the hospital continues to focus on its clinical documentation improvement (CDI) program. He says, “We are teaching physicians ‘ICD-10 light.’ They don’t necessarily know they’re learning I-10, but the crux and cornerstones of ICD-10 are what our program is based on. We give them info in small digestible bites, things they need to know right here, right now to improve the quality of their documentation.”

For example, they reinforce and emphasize that physicians follow this rule: If you treated it, you diagnosed it, so you document it. As Holmes explains, “We take for granted that we see a string of data (e.g., lab or pathology results, signs or symptoms), and physicians synthesize the information in their heads instead of documenting it.” The goal is to get the physicians to put their thought processes on paper.

Although this is a big challenge, the biggest challenge for the hospital is to “get everyone—physicians, nurses, coders, HIM staff, utilization review— heading in the same direction, getting on the same plate,” says Holmes.

Digging into the Data

For Cassidy, it is most “exciting” for HIM to have the luxury of time to become familiar with their own facility’s data, and do a critical analysis of their facility’s work flow to “identify missed opportunities, then fine tune and improve the weak areas.” As she says, “When hospitals do data analytics from the top level—say evaluating their top 20 MS-DRGs, they see not only the dollar sign change but also case mix index (CMI) changes. HIM is looking at the delay as an asset and reviewing processes from a strategic perspective not just the revenue cycle.”

The idea is to “focus on what you want in the future state to achieve better outcomes.”  With so many competing priorities, hospitals must review many things including the roles of coders and updating their coding compliance policies and rules. ”Really it’s just pushing the envelope on compliance, accuracy, and integrity,” she says.

Rode hopes that CMS itself will push the envelope, looking at a long-term map of how all of the required changes—ICD-10, meaningful use, bundled payments, ACOs—can be made in a reasonable fashion. He speaks for many in the industry when he says, “We need a strategic plan to allow the healthcare community to work together in these implementations.”

Janis Oppelt

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.