Making the Transition to ICD-10

Health care is going through a period of rapid change. Among them is the transition to ICD-10, the coding system that’s used to report medical diagnoses and procedures. Hospitals and physicians groups must be ready to make the switch by Oct. 1, 2014.

How does ICD-10 affect nurses? In general, they will need to document patient assessments and care with meticulous detail, so coders and billers can apply the correct codes later.

So why the change? Basically, after 30 years of use, the ICD-9 system is considered outdated – it no longer adequately reflects advances in modern medical practices and technologies. And because of its structure, the ability to add new codes is limited, so it no longer supports health reporting and payment processes very well. According to the American Health Information Management Association (AHIMA), ICD-10 has already been in use across most of the world for the past decade, with the U.S. woefully behind. The American system was adapted by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS), from a coding system developed by the World Health Organization (WHO).


A New Focus on Details
The greatest difference in ICD-10 is the level of specificity that it achieves – more than 100,000 codes have been added to the two versions of the system that cover inpatient and ambulatory care. The codes are now based not only on the type of diagnosis or procedure being defined, but on the exact body part affected and other clinical details. For example, a wound on the right leg will have a different code from a wound on the left leg, and the initial patient visit for that wound will be coded differently than subsequent visits. This level of detail did not exist in ICD-9, so the additional information supplied by the new system is expected to benefit patients, providers, payers, and organizations that track and monitor the global spread of disease.

While the more specific codes are expected to confer many advantages, clinicians will also face the significant challenge of selecting the proper code every time they document care. Doctors may be surprised to learn that, while there were four codes for various manifestations of Crohn’s disease under ICD-9, there are more than 30 in ICD-10.  Nurses will find that pressure ulcers will have over 125 ICD-10 codes, up from nine under ICD-9.

The new level of specificity has been the source of much good-natured humor, particularly among health care bloggers, who have enjoyed pointing out the 312 new codes related to animal bites and attacks. An article in the Wall Street Journal featured the light-hearted headline “Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way,” along with the tongue-in-cheek tagline New Medical-Billing System Provides Precision; Nine Codes for Macaw Mishaps. As it explains:

Indeed, health plans may never again wonder where a patient got hurt. There are codes for injuries in opera houses (see code), art galleries (see code), squash courts (see code) and nine locations in and around a mobile home (see codes), from the bathroom to the bedroom. It will also have a code for recording that a patient’s injury occurred in a chicken coop. (See code.)

With ICD-9, codes were three to five digits. In ICD-10, however, they can be up to seven digits long and always begin with a letter. They look like this, in terms of structure and level of detail:


Unspecified fracture of shaft of left ulna


Initial counter for closed fracture


Initial encounter for open fracture type I or II


Initial encounter for open fracture type IIIA, IIIB, or IIIC


Subsequent encounter for closed fracture with routine healing


Subsequent encounter for open fracture type I or II with routine healing


Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing


Subsequent encounter for closed fracture with delayed healing


The Nursing Perspective
So how does ICD-10 affect nurses? In general, they will need to document patient assessments and care with meticulous detail, so coders and billers can apply the correct codes later. In some cases, they may even have to go back to physicians for more information. If nurses are not adequately trained in ICD-10 clinical documentation requirements, insurance payments to patients or providers may be delayed or denied.

Advanced practice nurses and nurse case managers who deal with patient insurance may be more directly affected by the transition to ICD-10, as they may be assigning the proper codes themselves.

Nurse informaticists may also be called upon to help with the transition from ICD-9 to ICD-10, as hospitals and physician practices work to modify clinical documentation processes and workflows.

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