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With 14,000 medical codes, the old collection of codes – the ICD-9- seems puny by comparison. The new manual for ICD-10 explodes that code set to 68,000 much more granular and detailed terms to define — very exactly what health problems can occur.

The ICD-10 manual is thick, about the size of a phone book. Printed in minuscule type on newsprint-thin paper, it weighs five pounds and includes more than 1,100 pages of medical procedures and ailments. The index alone — the guide to figuring out where to find the right code — is 421 pages.

The ICD-10 manual is big. Really big. (Carla Broyles)

Two key factors help explain the explosion in medical codes. First, ICD-10 adds in the ability to differentiate between left and right sides of the body. This can help insurers, for example, to root out fraud. A hip replacement on both the left and right side might not raise any red flags — but two hip replacements on the left side probably would.

Second, the new codes categorize whether a trip to the hospital was the first round of treatment or a subsequent encounter. This is important for reimbursement purposes, as first visits to the doctor tend to require more resources.

Whether this specificity improves the medical system is a subject of fierce debate in health technology circles. Opponents argue that the new larger set will slow productivity, making it more difficult for veteran billers to find the right code in a sea of parrot injuries and turkey bites.

Most other industrialized nations transitioned to ICD-10, which the World Health Organization published in 1992, more than a decade ago. The switch can take years because most countries come up with a slightly modified version of the code set that best suits their needs.

When Canada adopted ICD-10 in 2001, one study of a Toronto hospital system showed that productivity fell by half. Before ICD-10, medical coders could get through 4.62 charts in an hour. Right after the transition, that fell to 2.15 charts per hour. One year later, productivity had partially rebounded to 3.75 charts per hour.

“If you look at Canada’s transition, there were some longer term cost impacts that went well beyond the transition itself,” said Michael Nolte, chief operating officer of technology firm MedAssets. “There’s some evidence that there will be a long-term effect.”

One study funded by the American Medical Association estimated that it could cost doctors’ offices $56,000 to $8 million to transition to ICD-10, depending on the size of the practice. The AMA, one of the larger groups opposed the switch, is still petitioning the federal government to reverse course.

“Adopting ICD-10, while it may provide benefits to others in the health-care system, is unlikely to improve the care physicians provide their patients and takes valuable resources away from implementing delivery reforms and health information technology,” the trade group wrote in a Feb. 12 letter to Health and Human Services Secretary Kathleen Sebelius.

Others contend that the change in productivity won’t be as dramatic — that opthalmology coders could just stick to the ophthalmology section, for example, and don’t have any reason to get bogged down in codes about parrots. Health insurers don’t care if a bite came from a parrot or a turkey — they just want to know what type of medicine they’re paying for when the hospital treats it.

“No individual has to use the whole thing,” said Martin Libicki, a researcher at RAND Corporation. “If you’re working with an eye doctor, God knows why you’d learn the codes for broken legs. But if someone showed up with a broken leg, you would just look it up.”

Libicki authored a major RAND Corporation study in 2004 — when the Bush administration was first studying the transition — that estimated the potential benefits of switching to ICD-10 outweighed the costs by as much as $4.5 billion.

Much of this comes from increased specificity in coding, which both makes it easier to accurately pay hospitals for the care they provide — and reduces opportunity for fraudulent billing.

“If you have ICD-10, you have an enormous increase in precision,” said Richard Averill, senior vice president of clinical and economic research at 3M Health Information Systems, recalled. He has worked in the medical coding world for decades, and his company has a key federal contract to help run the ICD-10 transition. “Yes, there’s an adjustment, but two years later you’ve gotten rid of a lot of that paper chase.”

In a more precise coding system, researchers see the potential to better track the quality of medical care that patients receive. Billers can denote whether a visit to the hospital is a first, second or later trip — which could indicate the severity of the condition.

Nearly everyone agrees that there is at least one compelling reason to switch to ICD-10: As new medical technologies have come online and demanded new codes, ICD-9 has run out of space. The capacity for noting cardiology procedures (assigned, in ICD-9, by codes that begin with “37”) was exhausted in the early 2000s. That created a patchwork scenario, where new cardiology codes show up elsewhere in the code set, with little rhyme or reason.

“The consequence is very disruptive,” said Christopher Chute, a professor at the Mayo Clinic and expert on medical classification. “It’s like they’re renovating a city, and assigning addresses at random. That makes it a lot more difficult to find the right house.”

In 2012, Chute wrote an article in the journal Health Affairs advocating for delaying the ICD-10 implementation. He has serious doubts about whether the new codes will improve the medical system. But he also doesn’t see any better option right now: The code set the country currently uses has no space left to grow.

“It’s now equally important for private payers, in terms of a backbone of how bills get paid,” Michael Nolte said, chief operating officer of technology firm MedAssets. “It’s just as fundamental.”

When the Centers for Medicare and Medicaid Services first explored a move to ICD-10 more than a decade ago, health insurance plans began diligently preparing. Medical billing trainers started developing their her ICD-10 curriculum. No one imagined they would still be getting ready a full decade later.

Flipping the switch

Nobody in the medical community is quite sure what will happen on Oct. 1, when the US federal government flips the switch on this new system.

“I think it will be a non-event in the same way Y2K was,” Gordon, the woman with the workplace stress pin, said. “I have such confidence in our health-care providers. They’re not going to enjoy it, but they’ll be ready.”

Others aren’t quite as sanguine.

“The difference is Y2K was only a technical issue,” Nolte, of MedAssets, said. “You didn’t have to ask anybody to do anything different. But here you have a culture change, where you’re teaching thousands of people to do something that’s somewhat foreign to them.”

The federal government has undergone a massive data mapping project, figuring out which codes from ICD-10 will replace each and every code from ICD-9. Technology firm 3M, where Averill works, has one of the major contracts to complete that process.

This month the agency announced it would hold a testing week in March, where hospitals can check if their new ICD-10 claims make it to the federal government. While those are the only testing plans in place for the moment, the agency says it’s confident that it will be able to handle the new codes come October. More of the concern tends to center on smaller, private health insurance plans, who which don’t have the resources of the federal government to prepare.

Regardless what happens this year, even more change is in the works: In 2007, Chute, at the Mayo Clinic, began leading the World Health Organization’s efforts to develop the Eleventh Edition of the International Classification of Diseases, or ICD-11. He expects that to come into use in the United States sometime around 2022.

“I think we’ve had about tens of thousands of person hours put into this already,” Chute said. The effort relies on hundreds of committees with thousands of doctors around the world, each leading experts in their medical specialities.

Reolubin made it through the San Francisco training. It’s nearly certain she won’t be around for the next ICD upgrade — and she says, only partially joking, she thinks sometimes about skipping this one, too.

“I keep telling my boss, ‘I’ll just retire,’ ” she says, as she highlights her new, ICD-10 code book. “I’ve done this for long enough.”

Sarah Kliff
Sarah Kliff covers health policy, focusing on Medicare, Medicaid and the health reform law. She tries to fit in some reproductive health and education policy coverage, too, alongside an occasional hockey reference. Her work has appeared in Newsweek, Politico, and the BBC.