Based on the most recent draft of ICD-10, American urologists and their patients may not derive as much benefit from ICD-10 as its proponents claim. To understand its urologic implications, a brief review of ICD-10 is in order.
ICD stands for International Classification of Diseases. Historically, the ICD concept first appeared in France in 1893 and was known as the International List of Causes of Death. The WHO assumed responsibility for the ICD in 1948 with the goal to standardize medical diagnosis and track diseases worldwide. These systems are now also used to more accurately classify reimbursement rates. In 1979 the current ICD-9 was created. For some time it has been recognized that the ICD-9 system did not provide sufficient detail to accurately characterize the disease and care of patients as medical technologies advanced, leading to the new and hopefully improved ICD-10.
Many countries, all with a single payer national health system, have already adopted ICD-10: Australia (1998), Canada (2000) and France (2005). There are many more codes in ICD-10 than ICD-9 (approximately 68,000 versus 13,000) as the codes have become more specific. Diseases must now be distinguished based on laterality (left versus right) and the number of characters in the system has been expanded from 5 to 7. (Note that technically the US is adopting ICD-10-CM, an approved clinical modification of the ICD-10 classification). (http://www.cdc.gov/nchs/icd/icd10cm.html)
Did you know that the entire draft of the ICD-10 list, and the preliminary crosswalk between ICD-9 and ICD-10 were made available on the National Center for Health Statistics (NCHS) website for public comment in 1997 (yes 17 years ago)? The American Hospital Association and others conducted a field test for ICD-10-CM in the summer of 2003. If you feel a little like Rip Van Winkle and find this hard to believe you can confirm these dates (http://www.cdc.gov/nchs/icd/icd10cm.html).
The adoption of ICD-10 in the US is met by either enthusiasm or fear based on how this next unfunded mandate impacts your daily activities. The government, insurers and vendors of health information services appear joyful. ICD-10 enthusiasts indicate a lower coding error rate than ICD-9 and fewer erroneous and rejected reimbursement claims because these ICD-10 codes are “less ambiguous and more logically organized and detailed”. More cynically, could it be that the new system will make payment rejections easier through unintentional incorrect coding using a new and much more complex system? Many health information vendors and coding companies see new business opportunities with the growing need for expanded services, webinars and consultants to allow physicians to keep up with this program that will impact every patient encounter.
On the other side, physicians have been warned that they may face disruptions in payments even if they are on target to operate using ICD-10 on the delayed mandatory adoption date of October 1, 2015. Practices are encouraged to have contingency plans in place in case providers and payers experience disruptions in the program. Keep in mind the roll out and disruptions of the healthcare.gov system in the fall of 2013. Further, as an unfunded mandate, the significant costs will be borne by the practices. Computer, EHR and billing system upgrades and the cost of training staff are at the expense of the providers. The AMA has estimated that a small practice can expect to spend up to $226, 105 with larger practices and health systems spending millions of dollars. Experts advise having up to 6 months cash reserves or the ability to secure a line of credit to avoid potential hardship caused by the ICD-10 implementation. It is easy to see why the exuberant endorsement of ICD-10 by some cannot be met in the same light by US providers.
How will urology fare in ICD-10? The prognosis is mixed. ICD-10 does enhance urology practice in limited areas. Urethral strictures are now classified by specific location as opposed to the singular listing in ICD-9. Likewise specific causes of priapism, impotence and sperm defects are now more clearly categorized. Medical renal diseases get a big boost in the numbers of specific diagnosis codes with very precise histologic classifications.
Prostate cancer and prostatocystitis: Equal in the eyes of ICD-10 Where does ICD-10 fail urology? Prostate cancer, the leading solid malignant tumor in men, whether low or high risk, locally advanced or organ confined, still gets only one code (C61) as it did in ICD-9. Metastatic prostate cancer will now have specific site codes. Renal (N20.0) and ureteral (N20.1) calculi, regardless of size, composition or complexity are coded identically while the work effort and potential for complications and outcomes varies greatly. A staghorn calculus is coded the same as a 2 mm lower pole stone. Kidney cancer gets a code for the very uncommon carcinoid tumor of the kidney (C7A.093) but beyond that kidney cancer (C64) is just kidney cancer without regard to histologic type or size of the tumor. Prostatocystitis, present in ICD-9 persists in ICD-10 (N41.3). Since I was not familiar with this diagnosis important enough to have its own code, a Medline search pulled up only one paper translated from German using the term prostatocystitis. While the framers of the ICD system and SNOMED consider prostatocystitis worthy of a precise classification, I will not be adding it to the next edition of the “Five Minute Urology Consult”.
ICD-10 serves some areas of health care and medical specialists better than others. As noted by the Secretary of HHS “ …we believe it is important to require implementation of ICD-10 as soon as the law permits because it will allow the industry to begin reaping the benefits of ICD-10 as soon as possible”. My interpretation of this endorsement: industry is code for the business side of medicine such as fee schedules and reimbursements to the one sided benefit of CMS, insurance companies and vendors of health information services. According to the American Health Information Management Association, participants in the early ICD-10 testing: “Increasing the detail and better depicting severity will help clarify the connection between a provider ’s performance and the patient’s condition. In addition, ICD-10 greatly expands the codes for medical complications and medical safety issues”. This group also states that “… the new code sets will also permit improved efficiencies and lower administrative costs due to replacement of a dysfunctional classification system”. Providers must ask “lower administrative costs for whom?” as they are hit with tens of thousands of dollars of unreimbursed ICD-10 costs. How functional is this new classification system that now includes codes for being sucked into a jet engine (V97.33XD) and burns due to water skis on fire (V91.07XD)?
If ICD-10 is to more accurately classify diseases, treatments, complications, quality outcomes and improve public healthcare, the benefits to urologists and our patients are not clear for some of the most common conditions we treat. Failure to capture the differences in properly classifying patients with prostate cancer, kidney cancer and urolithiasis raises important questions on the applicability of the ICD-10 dataset as a metric for any analysis be it disease specific outcomes or reimbursement.
The ICD-10 is a non-negotiable governmental mandate that will burden all practicing physicians. The AMA and more than 80 other medical associations failed in their attempt to stop implementation of the ICD-10 due to the excessive regulatory challenges that practices are already dealing with such as the components of the Affordable Care Act, ePrescribing, EHR meaningful use and quality reporting.
When it comes to urology ICD-10 falls short in capturing important characteristics of many major urologic diseases. But have no fear. ICD-11 is already in production and scheduled for release in 2017. I hope that prostate cancer gets more attention than prostatocystitis in the next version.
Leonard G. Gomella, MD Thomas Jefferson University Philadelphia, PA
© The Canadian Journal of Urology™; 21(4); August 2014