ICD-10 and Urologic Oncology: A Disappointing Combination

Leonard G. Gomella, MD
Published: Friday, Oct 24, 2014
Sidney Kimmel Cancer Center Sidney Kimmel
Leonard G. Gomella, MD
Chair, Department of Urology
Director, Kimmel Cancer Center Network
Jefferson University HospitalSAP
The 12-month countdown to the adoption of ICD-10 has begun. ICD-10 represents the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (usually referred to as “ICD”), now overseen by the World Health Organization (WHO). The overall goal of the ICD project is to standardize medical diagnosis and track diseases worldwide with the use of uniform codes to improve consistency among physicians and hospitals in recording patient symptoms and diagnoses.

These systems are now also used to more accurately classify reimbursement rates. Although the United States will be adopting this upgrade to ICD-9, we are actually one of the last major countries to implement the ICD-10 system.

While the United States is technically set to begin using a modification known as ICD-10 CM (Clinical Modification that also tracks morbidity data) in October 2015, many other countries such as Australia, France, Germany, China and Canada have been using the system for many years. The ICD-10 system is not new and has been in existence for nearly 20 years.

How much input medical specialists had in the process is a curiosity that needs more study. The modifications to this system are illogical for some diseases such as prostate and kidney cancers. Localized pancreatic and breast cancers get 9 primary codes in ICD-10 based on location of the malignancy. Only one code each is given for localized kidney cancer (C64) and localized prostate cancer (C61). While one might argue that the specific location of pancreatic or breast cancer is more critical in the prognosis and treatment, there are other critical features that distinguish management and outcome of cancers such as renal cell carcinoma and adenocarcinoma of the prostate.

For non-metastatic localized kidney cancer, tumor size, histology, intrarenal versus extrarenal extension, and the presence or absence of tumor thrombus can have significant implications for treatment. This treatment can range from surveillance to partial nephrectomy, and radical nephrectomy with or without vena cavotomy. Some patients may even need cardio-pulmonary bypass to remove an extensive vena caval thrombus. Alas, one code covers them all, with one unimportant exception: noting if it is a left- or right-sided tumor. Prostate cancer, the most common solid tumor in men in the United States and the second leading cause of cancer death, also gets one code for localized disease. Again, the ICD-10 system ignores the important clinical aspects of how localized prostate cancer is managed, ranging widely from active surveillance through aggressive multimodality therapy that may include combinations of surgery, radiation, and systemic therapies.

The Secretary of Health and Human Services (HHS) wants the ICD-10 implementation to occur as soon as possible to “begin reaping the benefits” of this much more complex system. Estimates are that the expansion of the number of codes from the current ICD-9 of 17,000 will grow to more than 141,000 in ICD-10. According to an article on the website of the American Health Information Management Association (http://tinyurl. com/6ap2hyc), “Increasing the detail and better depicting severity will help clarify the connection between a provider’s performance and the patient’s condition. In addition, ICD-10 greatly expands the codes for medical complications and medical safety issues."

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