Experts Say ICD-10 Codes Don't Go Far Enough

Emily Brill
Published: Friday, Nov 04, 2016
Cindy Parman

Cindy Parman

When CMS switched from ICD-9 to ICD-10 last year, the new diagnosis classification list allowed coders to translate additional elements of doctors’ language to billers’ language. In a sense, ICD-10 added “adjectives” to coders’ vocabularies: oncology coders now have the ability to describe additional aspects of a tumor, such as whether it resides in the upper left or lower right quadrant of a patient’s lung.

Some coders would like to see that vocabulary expand further, particularly in the area of comorbidities and complications. “Oncology needs to get better at coding things that are not neoplasms—complications of care, or patients who show up with comorbidities,” said Cindy Parman, a principal at Coding Strategies Inc., a Georgia-based coding education and consulting company. “If a patient already has congestive heart failure, it may change the drug we're going to give the patient. I think oncology coders could use more codes like that—more codes for adverse events of care.”

In interviews with Oncology Business ManagementTM, oncology coders and practice administrators also said they see room for improvement in the coding of genetic mutations, staging information, and tumor behavior.

When Hoang Nguyen codes an inpatient oncology visit at the Boston-area hospital where he works, he pays special attention to patients’ comorbidities.

“The comorbidities will complicate treatment. If they've had kidney failure or congestive heart failure, that will make it harder,” said Nguyen, a coding instructor who does work for South Shore Hospital in South Weymouth, Massachusetts. Medicare bases its payment system for inpatient hospital stays around a concept called the Medicare Severity-Diagnosis Related Group (MS-DRG).

Hospitals bundle procedure codes under a DRG, and payers use it to assign a flat fee that they stratify based on complications and comorbidities. “So, diagnosis coding drives the payment for MS-DRGs,” Parman said.

Independent oncology practices, which specialize in outpatient care, don't use the MS-DRG system. Physicians are paid based on relative value units, which take into account the amount of work expended by a physician to treat a patient. However, a payment scheme more akin to the MS-DRG-based model may be in the works for outpatient care, Parman said.

Under the Patient Access and Medicare Protection Act of 2015, Congress directed CMS to submit a report on the development of an alternative payment model for radiation services in a nonfacility setting. Such a model would allow for greater specificity in billing, which would require greater specificity in coding.

“They're doing this already on an inpatient basis, and translating it to an outpatient basis wouldn't be that hard. But it would be hard for independent oncology practices that aren't fully classifying each one of their patients,” Parman said. “If everybody's sending in the same procedure code, how are we going to differentiate payment based on quality and value? Well, what we have are the ICD-10 diagnosis codes.”

Room for Improvement

The inadequacies of ICD-10’s diagnosis codes once sparked a conversation among Tracie Whitley’s staff at the Regional Medical Oncology Center in Wilson, North Carolina. The biggest bugbear was the code set's lack of accommodation for “the genetic mutation pieces” of a cancer diagnosis, Whitley said. “It would be great if we could have those as an add-on digit to the cancer code,” she said. “A lot of the drugs now are specific to those genetic mutations, and that way, we can use it to explain why we coded for that drug.”

She also wishes a portion of the codes accounted for the progression of prior therapy. “We have a lot of drugs now where they want to see a patient had a previous line of therapy on a platinum drug, and they failed or progressed,” Whitley wsaid. “That's something we have to put in as a comment, whereas if we had a code, I think that would increase the efficiency of that process.” Amy Lawhead, a business analyst at the Oklahoma Cancer Specialists and Research Institute, says tacking additional elements onto codes and making them more precise would only benefit the oncology field. Coding expert Bobbi Buell said billers probably wouldn't like it—“If you're a biller, you're stressed out enough,” she said.

Several coders added that the people on their end would be more than happy to accommodate sharper attention to detail. “I’m one of those coders—and most coders are, I have to say—where I like codes to be as detailed as possible,” said Heather O’Leary, of the Santa Barbara Cancer Center at Sansum Clinic. “So, when these new codes come out and it's so specific, we like that.”

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