As a group, radiologists don’t tend to leap at the opportunity to standardize. Take CPT coding and RVUs for example. Most radiologists still have little understanding of how CPT coding and RVUs work together. There is a vague idea that each CPT code is associated with an RVU that in some way is used for billing. So, when ICD-10 is discussed, in most cases, we might as well be speaking a foreign language.
By definition, ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD). In short, this is a classification system created by the World Health Organization (WHO). There are 2 types of ICD-10 codes, diagnosis codes and procedure codes. The diagnosis codes relate to coding for specific or general diseases, physical signs and patient symptoms. Procedure codes relate to the procedures provided as a service to patients. ICD-10 is a significant change from the most recent ICD-9 version. Specifically, there is a massive increase in coding primarily related to specificity.(Fig. 1.)
FIGURE 1. Changes in numbers of codes from ICD-9 to ICD-10:
Procedure codes: ICD9 3,824 ICD10 71,924
Diagnosis codes: ICD9 14,025 ICD10 69,823
What many radiologists don’t realize is that ICD-10 coding, while more laborious and difficult to learn, is really a substantial improvement from what we have seen in the past. ICD-10 will require the types of histories and information we have long sought when providing our interpretations. Histories will have to be much more specific, complete and accurate in order to derive accurate ICD-10 coding for billing. This increased information and specificity will have significant benefits allowing radiologists to deliver a more specific diagnosis or detailed differential diagnosis for any given finding.
Most of the increased information and specificity will come from improved data collection from the patient, clinician and hospital. This will coincide with a need for an improved level of detail and specificity in a radiologist’s interpretations.
There are total of 7 potential levels for each code e.g. 7 different numbers and/or letters, with each subsequent number and/or letter increasing the specificity and identification of the process involved.
For example: S42.414A is a closed, nondisplaced, simple supracondylar fracture without an associated intercondylar fracture of the right humerus, initial encounter. S42.461K is a displaced fracture of medial condyle of the right humerus, subsequent encounter for fracture with nonunion.
There are four specific areas where radiologists should pay special attention. Laterality and age, episodes of care, fractures and anatomic specificity/location of disease.(Fig. 2.)
FIGURE 2. Areas of ICD-10 coding requiring specific attention by radiologists:
Laterality and age.
We need to be specific about whether a process or history is left, right or bilateral e.g. left shoulder, right hand, bilateral feet.
Age: Acute, subacute, residual, recurrent, traumatic.
Episodes of care.
Encounter Type: is defined as the period when the patient is being actively treated and is typically used for accidents and injuries. These can be defined as initial encounter, Subsequent, Sequela.
Initial encounter: The first interaction for diagnosis and active treatment (e.g. ankle x-ray for ED patient after twisting injury that day) .
Subsequent: An interaction occurring after the initial diagnosis and treatment completed (e.g. follow up x-ray four weeks after casting to check healing).
Sequela: Complications or conditions that arise as a direct result of a condition (e.g. nonhealing wound after open ankle fracture or nonunion of the fracture).
Fractures.
Open or closed. If open, description of the soft tissue injury.
Location of fracture is important. Proximal, distal, shaft, metaphysis and discussion of involvement of the articular surface.
Orientation of the fracture: Vertical, spiral, oblique, avulsion, greenstick, comminuted and degree of angulation.
Traumatic or pathologic.
Subsequent/sequela: Healing Status – Routine, Delayed, Nonunion, Malunion
Anatomic specificity/location of disease.
“ICD-10 is going to be easy,” said no one, ever!
The fact that ICD-10 has been delayed in implementation and in general, complete implementation is going to have a one-year grace period, should lead everyone to the conclusion that ICD-10 implementation is going to be hard. Clearly, there will be benefits and early adopters will reap those benefits sooner than those who drag their feet. Radiologists need to be leaders and early adopters, and once understood even at a superficial level, nearly every radiologist will immediately grasp the vast improvement in patient care that can be seen with improving specificity and communication.
Finally, by adopting, learning and understanding ICD-10 and its improvements, it is the patient who will reap the most benefit from ICD-10 with improved patient care and potentially lower costs.
