The health care system in the United States is preparing for one of the biggest challenges it has faced in decades. No, not socialized medicine or universal health care, but the overwhelming task of transitioning from the ICD-9 coding system to the ICD-10 system. The price tag? An estimated $83,290 for a small (i.e., three-doctor) practice. The total cost for the entire U.S. health care system? $1.64 billion.

Conservative estimates project that we will be moving from a system that contains about 14,000 diagnosis codes to a system that contains some 68,000 diagnosis codes.
If youre wondering what is behind all of the angst, a little history lesson may prove beneficial.


History and Perspective

The International Classification of Diseases (or more specifically, the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, or ICD-10) is the latest in a series that has its origins in the 1850s with a collection of mortality statistics. The first edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893.

The World Health Organization (WHO) took over the responsibility for the ICD in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published.

The ICD is designed to promote international comparability in the collection, processing, classification and presentation of mortality and morbidity statistics. It is used to classify diseases and other health problems recorded on many types of health and vital records, including death certificates and patient records. The reported conditions are then translated into medical codes in accordance with the classification structure and the selection and modification rules contained in the applicable revision of the ICD.

The International Conference for the Ninth Revision of the International Classification of Diseases, convened by WHO, met in Geneva in 1975. A number of innovations were included in the ninth revision, aimed at increasing its flexibility for use in a variety of situations. But, after several years, the ICD-9 eventually ran its course. In May 1990, the ICD-10 was endorsed by the 43rd World Health Assembly and came into use in WHO member states as early as 1994.



So, if WHO completed the ICD-10 more than a decade ago, why hasnt it been phased in yet?

First, understand that WHOs ICD system and the system that you use for coding and billing are not one and the same. In 1979, the United States adapted the ICD-9 classification system (as many other countries have) to capture additional morbidity data, and called it ICD-9-CM (the last two letters stand for Clinical Modification). More functionally, ICD-9-CM added procedure and diagnosis codes that eventually were used for the reimbursement process of health care encounters. (The CM codes are more precise than those in WHOs ICD-9, which are needed only for statistical groupings and trend analysis.) Since the late 1980s, ICD-9-CM has been required by third-party payers for reporting the clinical diagnosis associated with the performed procedures.

In the U.S., ICD-9-CM is used to code and classify morbidity data from inpatient and outpatient records, physician offices and most National Center for Health Statistics (NCHS) surveys. NCHS and the CMS are the governmental agencies responsible for administering all changes and modifications to ICD-9-CM. An annual review process makes changes to the ICD-9-CM to further clarify some codes and to create new codes needed as a result of discoveries, medical advancements or other administrative reasons.

Despite the annual revisions, the U.S.s ICD-9-CM has begun to show its age, and a revised system was called for. In the 1990s, NCHS received permission from the WHO to create a clinical modification of the ICD-10.


ICD-10: Why, and Why Now?

Fall 2008 was exciting, to say the least, with the political change sweeping our country. In the coding world, there was much excitement as well. CMS announced that the final implementation date for the expanded ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) code sets would be October 1, 2011.

In response, many health care organizations around the country protested loudly, saying that this date was too soon and that the cost and time impact of implementing the ICD-10 rules would be overwhelming to our health care system. Continued debate ensued and, earlier this year, CMS postponed the implementation date to October 1, 2013.
The October 1, 2013 implementation date is a firm onein other words, ICD-9 codes cannot be used to report services performed after that date. In order to avoid entities from having to maintain the capacity to work with both coding systems after that date, the implementation of crosswalks, mapping and guidelines will enable them to move from ICD-9 to ICD-10 on and after this date.

The impetus to move to the ICD-10 comes from many different forces. The ICD-9 is 30 years old, and is outdated. Many of the diagnostic categories are full and cannot be expanded to add new entries. And, for those categories and diagnoses that do exist, many are not descriptive enough.

Specifically, ICD-9-CM includes about 14,000 diagnosis codes. Under ICD-10-CM, there will be about 68,000 codes. The number of procedure codes will increase from some 3,800 under ICD-9 to about 87,000 under ICD-10.

Also, the code structure itself will change. With the current ICD-9 diagnosis codes, each code has three to five digitsand most have five because we are obliged to always code to the highest level of specificity. There are 17 distinct chapters in the ICD-9, with all characters being numeric (except for supplemental diagnosis codesE and Vin which the first character is alpha and the remainder are numeric).

The ICD-10 is a completely different system. An ICD-10 code:

Is three to seven digits long.

Begins with an alphabetic character. 

Has a numeral as the second digit. 

Includes alpha or numeric digits as the third through seventh characters.

Differentiates right vs. left vs. bilateral.

Government-produced algorithms that map a specific code from the ICD-9 to the ICD-10, or vice versa, have had limited success to date. But, Im hopeful that with time, they will become more accurate.

ICD-9 vs. ICD-10 Glaucoma Codes

ICD-9 Description  ICD-10 Description
365.00 Pre-glaucoma, NOS        H400 Glaucoma suspect

365.01 Open-angleborderline findings

H400 Glaucoma suspect
365.02 Anatomical narrow-angle glaucoma H400 Glaucoma suspect
365.03 Steroid-response glaucoma H400 Glaucoma suspect
365.04 Ocular hypertension   H400 Glaucoma suspect
365.10 Open-angle glaucoma, NOS  H4010 Unspecified open-angle glaucoma
365.11 Primary open-angle glaucoma H4011 Primary open-angle glaucoma
365.12 Low-tension glaucoma

H40121 Low-tension glaucoma, right eye       

365.12 Low-tension glaucoma H40122 Low-tension glaucoma, left eye
365.12 Low-tension glaucoma H40123 Low-tension glaucoma, both eyes

365.12 Low-tension glaucoma       

H40129 Low-tension glaucoma, unspecified eye


Benefits and Savings

There will be several major benefits to switching over to the ICD-10 system, according to the U.S. Department of Health and Human Services (HHS):

More accurate payments for new procedures.

Fewer rejected claims.

Fewer improper claims.

Better understanding of new procedures.

Improved disease management.

Better understanding of health conditions and health care outcomes.

Harmonization of disease monitoring and reporting worldwide.

In dollars and cents, benefits of the conversion to ICD-10 would start in 2013 with about $87.7 million in annual savings, according to HHS. It estimates that the cumulative benefit of the conversion will be about $3.95 billion by 2023. However, the changeover will be costly, and those costs wont break even until 2018.


Costs and Labor

The total conversion from ICD-9 to ICD-10 will cost about $1.64 billion over at least six years, HHS estimates. This total includes costs for training ($356 million), productivity losses ($572 million) and system changes ($713 million).

In every office and facility that provides health care, the changeover to the ICD-10 system will create significant challenges. These include costs and time in different areas, such as doctor and staff education and training, new claim form (Superbill) software, upgrades for practice management and billing system software, increased documentation and loss of cash flow.

Cost Impact of ICD-10 for a Small Practice


Typical three-doctor practice
Education $2,405
Process analysis $6,900
Changes to Superbills $2,985
IT costs $7,500
Increased documentation $44,000
Cash flow disruption $19,500
Total $83,290 

Source: Nachimson Advisors, LLC. The impact of implementing ICD-10 on physician practices and clinical laboratories. Reistertown, MD: Nachimson Advisors; 2008 Oct 8:6.

One of the key issues will be having to maintain both systems in practice for at least a year while this transition is taking place. Generally, health care claims can be filed with a third-party insurer up to one year past the date of service.

Theoretically, all patients that you provide care for between October 1, 2012 and September 30, 2013 could be filed or refiled up to September 30, 2014, but you would have to use the ICD-9 diagnostic codes for these claims, as the ICD-10 wouldnt have been in force yet. This is an area of substantial concern of minesignificant delays in claims processing are conceivable.


There will be much, much more written on this topic before the October 1, 2013 implementation date. What you should do now is become familiar with the timeframe, set goals and target dates of education, work with your software manufacturers to find out how they are incorporating the ICD-10 system into their products and, most importantly, stay up-to-date by understanding where resources for the ICD-10 can be found. (See More Information on ICD-10, below.)

Theres no doubt in anyones mind that our industry is a dynamic one. The world of coding is no different. Change occurs on a daily basis, whether its in a reimbursement value, a new rule or regulation, or interpretation thereof that places the practitioner at risk.

They say that the path of change is a bumpy one. The U.S. health care system will certainly encounter many potholes as we go down this path, transitioning from the ICD-9 to the ICD-10.

In the end, we should have a system that is more accurate, more descriptive, allows for better reimbursements, and keeps us as a country current on the world stage.

Stay tuned for further developments as we go on this journey together.


More Information on ICD-10

General ICD-10 information

ICD-10 Notice of Proposed Rulemaking

ICD-10-CM information and equivalence mappings for ICD-9-CM to ICD-10-CM

ICD-10-CM/PCS to ICD-9-CM reimbursement mappings


Vol. No: 146:05Issue: 5/15/2009