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Introduction

Primary care physicians are up in arms about the International Classification of Diseases, Tenth Revision (ICD-10), and no doubt the new diagnosis system is complex and highly specific. But although the transition will create some upheaval and loss of time, in the long run ICD-10 may bring financial and clinical benefits for primary care doctors.

The biggest complaint is that ICD-10 contains lots more codes: 68,069 in the 10th edition compared with the 14,035 currently in use. Despite the widespread consternation, this change was inevitable. The current diagnosis coding system -- the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) -- is outdated. And the 10th edition, which is only now being adopted, was introduced in 1992, so it's no spring chicken either.

Much of the developed world has been using a modified version of the 10th edition for more than a decade. Many hospital administrators in the United States have opposed it, because hospitals must convert to a new diagnosis coding system and will have to transition all inpatient procedure coding to the new ICD-10 procedure coding system. That process will undoubtedly consume a significant amount of resources.

The Centers for Medicare & Medicaid Services (CMS) estimates that hospital coders will require about 50 hours of transition training. That compares with 16 hours for physician coders. Even so, there's no question that 16 hours will be a burden for many primary care physicians, especially when you add in software upgrades and other transition costs.

Still, you may appreciate these benefits:

1. More Specific Coding

You'll be better able to integrate the reason why the diagnosis was given (bitten by a spider, for example) or characteristics of the patient getting the diagnosis, as well as the laterality of the body (ie, on the left arm). In contrast, ICD-9 did not require these elements, and the physician or coder was left to modify the code to be more detailed or use "unspecified," "not elsewhere classified," or "other" as coding choices. These choices often led to denials by insurance payers.

These nuances in specificity are defined in the current coding system, but users of ICD-9-CM must look to the rarely used "E" codes for the reason (E006.4, for example, is the current code for "activities involving bike riding"), and then add a modifier to the Current Procedural Terminology code, such as "LT" to indicate laterality (for example, 73130-LT is radiography of the left hand).

Perhaps the most comprehensive change in the transition to ICD-10 relates to the musculoskeletal system; it will affect everything from a simple evaluation of the patient who is experiencing pain to use of more complex services, such as joint injections and fracture care.

2. Finding a Possible Diagnosis Gets Easier

In ICD-10, you may find it easier to research unusual diagnoses, signs, and symptoms. Currently, if you cannot find a diagnosis, you must think of something similar and begin your hunt anew. With the 10th edition, very few -- and I meanvery few -- possible diagnoses are left unlisted.

Hunting for little-used diagnoses, whether by leafing through a written manual or searching in an electronic health record database, has always been a fact of life for physicians and coders. Yet, with ICD-10, you can still use a basic list of codes on your superbill. Ask your coder to convert your current list to ICD-10, and see how comprehensive it is. This will be a great exercise, because it's important for your staff to familiarize themselves with the new system, too.

3. Improved Description of the Extent of Diagnoses

You'll be more easily able to capture the breadth and depth of your patients' diagnoses. I've listened to many physicians who are frustrated when payers and others cannot seem to grasp how sick their patients are; with ICD-10, acuity will be captured and reportable. For example, asthma with chronic obstructive pulmonary disease is code J44.9 in ICD-10; in the current system, the closest you can get to that diagnosis is probably likely 493.20 -- chronic obstructive asthma, unspecified.

Indeed, up to 12 diagnoses can be reported for each patient in the new system. As the role of the primary care physician in the patient's medical home expands, this new tool will help you engage payers and other stakeholders in an enhanced understanding of your patient panel.

As the reimbursement landscape evolves, it's not a stretch to say that ICD-10 could be an invaluable aid to primary care physicians, particularly in the risk-adjusted reimbursement models now being initiated by payers. Although in its infancy, the reimbursement system is moving away from paying the same for code 99214 in a patient who presents with a sinus infection, compared with a patient with diabetes, heart failure, and emphysema -- in addition to the infection that prompted the visit. In fact, payers are beginning to recognize and reward primary care physicians for effectively managing patients with multiple acute conditions; and ICD-10 will further these efforts, because physicians can refine and report the complexity of the encounter.

4. It's Easier to Assign Codes

The increased specificity and reduced ambiguity of ICD-10 may actually make codes easier to assign correctly. Once the kinks are worked out of the system, the result should be fewer coding errors and fewer unpaid claims. With the need to amp up one's documentation to make ICD-10 functional, the more specific codes should decrease the volume of payers' requests for additional supporting documents.

My biggest worry about ICD-10? Workers' compensation. Although it may seem an odd concern in light of all the other issues, workers' compensation carriers are considered noncovered entities for the purposes of the Health Insurance Portability and Accountability Act (HIPAA). Although CMS is encouraging these carriers to comply with ICD-10, the fact is that they don't need to conform -- and experts anticipate that many won't, at least not at first.

Dealing with workers' compensation is challenging enough; I fear that primary care physicians will wonder whether it is worth the additional effort to convert ICD-10 codes back to ICD-9-CM codes in order to get paid by this one revenue source. Either way, the process of getting paid by workers' compensation will be an administrative nightmare.

Primary care physicians must also recognize the need to ensure that their order forms for laboratory tests, imaging studies, and other ancillary services include the correct ICD-10 diagnosis code -- one that is specific to the patient disease or injury, and with appropriate documentation in the medical record. If not, the hospitals, laboratories, imaging centers, and other ancillary providers receiving the requests will have no choice but to turn those patients away until an appropriate order form is submitted.

Further Notes about ICD-10

The 10th edition is accordingly more comprehensive, yet it retains the current scale's basic infrastructure: organization by chapters, with related diagnoses clustered together. Codes are still combinations of alphabetical letters and numeric digits. ICD-10 codes comprise 3 to 7 characters; the first is a letter, the second is a digit, and the third can be either. Like the ninth edition, the new codes have a decimal after the third character. For example, E10.5 is the code for insulin-dependent diabetes mellitus with peripheral circulatory complications.

Unlike a lot of government initiatives, the ICD-10 system isn't shrouded in mystery. The new scale is available and readily accessible. Take a look at the bi-directional mapping system between ICD-9 and ICD-10 that was authored by CMS and the Centers for Disease Control and Prevention. Called the General Equivalence Mappings, this is a great resource for recognizing the changes that will be applicable to your practice.

Although changing to ICD-10 may entail some challenging transitions, it's likely that with time, physicians will recognize its benefits. ICD-10 is certainly more complex, but its specificity may be advantageous to primary care physicians in this changing world of healthcare economics. Regardless, the system will be imposed on October 1, 2014, so be sure to take the time to understand how it will affect your practice.