ICD-10 has launched: Now What?

The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) code changes were implemented October 1, 2015 after more than 20 years and 10 revisions. The original ICD-10 was released by the World Health Organization (WHO) in 1993. It affects all Health Insurance Portability and Accountability Act-covered entities—hundreds of thousands of providers, payers and claims handlers. The codes are used to authorize and calculate trillions of dollars in payments from Medicare, Medicaid, commercial insurers, Tricare and the Veterans Health Administration to hospitals, physicians and other providers. ICD-10 is a much more complex and detailed coding system than ICD-9, which has been used since the 1970s. For providers, there are about 68,000 diagnostic codes under the new ICD-10-CM (clinical modification) codes—five times more than under ICD-9-CM. http://apps.who.int/iris/bitstream/10665/37958/8/9241544228_eng.pdf

The Centers for Medicare and Medicaid Services (CMS) issued a statement last week saying Medicare fee-for-service claims “are processing normally,” with 4.6 million a day being run through the agency’s Medicare Administrative Contractors (MACs), the same daily throughput as the agency’s “historical baseline.” The rate of Medicare claims rejected due to incomplete or invalid information is 2%, the same as normal, according to the CMS. The total Medicare claims denial rate for all reasons is 10.1%, up from a 10% baseline. This level of success despite a complex matrix of 87,000 new codes for hospital-based procedures in the ICD-10-PCS (procedural coding system)—29 times more codes than in ICD-9.

According to RelayHealth, the four key metrics measured to determine the impact of the ICD-10 conversions have had on organizations include – 1) days to final bill, 2) days to payment, 3) reimbursement rate, and 4) denial rate. For October, only 4) the denial rate has been above normal compared to monthly averages for July through September.

Converting diagnostic criteria into diagnostic algorithms which are incorporated into assessment instruments has provided a comprehensive blend of multi-systemic factors while uncovering inconsistencies, ambiguities and overlap from the previous version. The final result was a clear set of criteria for ICD-10 and assessment instruments which can produce data necessary for the classification of disorders according to the criteria. The original 1987 draft of ICD-10 used in the field trials had the merit of simplicity, for example, only mild and severe depressive episodes, no separation of hypomania from mania, and no recommendation to specify the presence or absence of familiarly clinical concepts, such as the ‘”somatic” syndrome or affective hallucinations and delusions. However, feedback from many of

the clinicians involved in the field trials, and other comments received from a variety of sources, indicated a widespread demand for opportunities to specify several grades of depression and the other features noted above. In addition, it is clear from the preliminary analysis of field trial data that in many centers

the category of “mild depressive episode” often had a comparatively low interrater reliability. All the major traditions and schools of psychiatry are represented, which gives this work its uniquely international character.

The classification and the guidelines were produced and tested in many languages. The diagnostic guidelines also provide a useful stimulus for clinical teaching, since they serve as a reminder about points of clinical practice that can be found in a fuller form in most textbooks of psychiatry. They are also suitable for some types of research projects, where the greater precision of the diagnostic criteria for research are not required. These descriptions and guidelines carry no theoretical implications, and they do not pretend to be comprehensive statements about the current state of knowledge of the disorders. They are simply a set of symptoms and comments that have been agreed, by a large number of advisors and consultants in many different countries, to be a reasonable basis for defining the limits of categories

in the classification of mental disorders.

These clinical descriptions and diagnostic guidelines were finalized after extensive field testing by over 700 clinicians and researchers in 110 institutes in 40 countries, making this book the product of the largest ever research effort designed to improve psychiatric diagnosis. Every effort has been made to define categories whose existence is scientifically justifiable as well as clinically useful. The classification divides disorders into ten groups according to major common themes or descriptive likeness, a new feature which makes for increased convenience of use. For each disorder, the ICD-10 book provides a full description of the main clinical features and all other important but less specific associated features. Diagnostic guidelines indicate the number, balance, and duration of symptoms usually required before a confident diagnosis can be made. Inclusion and exclusion criteria are also provided, together with conditions to be considered in differential diagnosis. The guidelines are worded so that a degree of flexibility is retained for diagnostic decisions in clinical work, particularly in the situation where provisional diagnosis may have to be made before the clinical picture is entirely clear or information is complete.

Interestingly, the number of searches on the website for re-classification have leveled off given the hype leading up to the October “go live” date.(see below)   Some have referred to the buildup and minimal amount of disruption after October 1st as similar to Y2K when everything was going to crash.            


May 2015                            0


June 2015                            0


July 2015                            0


August 2015                      256


September 2015                716


October 2015                    397


November 2015               143





ICD-10 is much larger than ICD-9. Numeric codes (001 -999) were used in ICD-9, whereas an alphanumeric coding scheme, based on codes with a single letter followed by two numbers at the three-character level (A00-Z99), has been adopted in ICD-10. This has significantly enlarged the number of categories available for the classification. Chapter V (F) of ICD-10 has 100 such categories.

The term “neurotic” is still retained for occasional use and occurs, for instance, in the heading of a major group (or block) of disorders F40-F48, “Neurotic, stress-related and somatoform disorders”. Except for depressive neurosis, most of the disorders regarded as “neuroses” by those who use the concept are to be found in this block, and the remainder are in the subsequent blocks. Instead of following the neurotic – psychotic dichotomy, the disorders are now arranged in groups according to major common themes or descriptive likenesses, which makes for increased convenience of use.

The term “psychogenic” has not been used in the titles of categories, in view

of its different meanings in different languages and psychiatric traditions. “Psychosomatic” is not used for similar reasons and also because use of this term might be taken to imply that psychological factors play no role in the occurrence, course and outcome of other diseases that are not so described. Disorders described as psychosomatic in other classifications can be found here in F45. – (somatoform disorders), F50. – (eating disorders), F52. – (sexual dysfunction), and F54. – (psychological or behavioral factors associated with disorders or diseases classified elsewhere).

The term “hysteria” has not been used in the title for any disorder in Chapter V (F) of ICD-10 because of its many and varied shades of meaning. Instead, “dissociative” has been preferred, to bring together disorders previously termed hysteria, of both dissociative and conversion types. By its very nature, coding in ICD-10 requires an elevated clinical understanding of disease processes, the clinical factors behind a diagnosis, and an ability to read and understand lab values and diagnostic reports.

It is recommended that clinicians follow the general rule of recording as many diagnoses as are necessary to cover the clinical picture. When recording more than one diagnosis, it is usually best to give one precedence over the others by specifying it as the main diagnosis, and to label any others as

Subsidiary or additional diagnoses. The dysfunction may be primary, as in diseases, injuries, and insults that affect the brain directly or with predilection; or secondary, as in systemic diseases and disorders that attack the brain only as one of the multiple organs or systems of the body involved.

On the one hand, there are syndromes in which the most prominent features are either disturbances of cognitive functions, such as memory, intellect, and learning, or disturbances of the sensorium, such as disorders of consciousness and attention. On the other hand, there are syndromes of which the most conspicuous manifestations are in the areas of perception (hallucinations), thought contents (delusions), or mood and emotion (depression, elation, anxiety), or in the overall pattern of personality and behavior.

Interesting ICD-10 Facts

Research carried out in various settings has demonstrated that a significant proportion of cases diagnosed as neurasthenia can also be classified under depression or anxiety: there are, however, cases in which the clinical syndrome does not match the description of any other category but does meet all the criteria specified for a syndrome of neurasthenia.

Anankastic is a personality disorder characterized by:

(a) feelings of excessive doubt and caution;

(b) preoccupation with details, rules, lists, order, organization or


(c) perfectionism that interferes with task completion

(d) excessive conscientiousness, scrupulousness, and undue preoccupation

with productivity to the exclusion of pleasure and

interpersonal relationships;

(e) excessive pedantry and adherence to social conventions;

(f) rigidity and stubbornness;

(g) unreasonable insistence by the patient that others submit to

exactly his or her way of doing things, or unreasonable reluctance

to allow others to do things;

(h) intrusion of insistent and unwelcome thoughts or impulses.

Notice the specificity of the Acute Intoxication diagnosis which returns as a transient condition following the administration of alcohol or other psychoactive substance, resulting in disturbances in level of consciousness, cognition, perception, affect or behavior, or other psychophysiological functions and responses.

The following five-character codes may be used to indicate whether the acute intoxication was associated with any complications:

F1A\00 Uncomplicated

Symptoms of varying severity, usually dose-dependent, particularly at high dose levels.

F1A\01 With trauma or other bodily injury

F1A\02 With other medical complications

Complications such as hematemesis, inhalation of vomitus.

Fix.03 With delirium

F1x.O4 With perceptual distortions

F1;r.O5 With coma

F1A\06 With convulsions

F1x.O7 Pathological intoxication

Harmful use and Dependence syndrome are a cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviors that once had greater value.

The diagnosis of the dependence syndrome may be further specified

by the following five-character codes:

F1x.2O Currently abstinent

F1x.21 Currently abstinent, but in a protected environment

(e.g. in hospital, in a therapeutic community, in prison, etc.)

F1x.22 Currently on a clinically supervised maintenance or

replacement regime [controlled dependence]

(e.g. with methadone; nicotine gum or nicotine patch)

F1x.23 Currently abstinent, but receiving treatment with aversive

or blocking drugs

(e.g. naltrexone or disulfiram)

F1x.24 Currently using the substance [active dependence]

F1x.25 Continuous use

F1x.26 Episodic use [dipsomania]

Butler, Mary. “Life After ICD-10: How the Healthcare World Will Change After ICD-10’s Implementation.” Journal of AHIMA 86, no.6 (June 2015): 22-27.