Time for Change - a Time for 10: Updating the Classification for Discharges On and After 1.1.05 to ICD-10-AM (The Australian Modification of ICD-10 and the Australian Classification of Interventions in Health)

Deirdre Murphy

Introduction

The Hospital Inpatient Enquiry (HIPE) scheme is a computer-based health information system designed to collect clinical and administrative data on discharges and deaths from acute care public hospitals. HIPE was established in 1971 and is the principal source of national data on discharges from acute general hospitals in Ireland. HI PE collects data on hospital discharges and maintains a national database of morbidity data from acute general hospitals in Ireland.

In 1989 with the introduction of ICD-9-CM and the start of case mix, clinical coding in Ireland has become a key area of interest for all stakeholders in the heath policy and research fields along with those working in many other areas in Ireland. Ensuring that the coding scheme in use for data collected on diagnoses and procedures performed is a challenge for all systems collecting hospital discharge abstract data. This challenge is even more acute in a small country like Ireland, which has to depend on the availability of current coding schemes in the international context rather than address the task of developing such schemes locally. Finding an integrated ICD-10 diagnoses and procedure classification is crucial for Ireland to remain a current and important participant in international health activity data collection projects. ICD-9-CM is the current classification in use in Ireland and is now in need of updating both to ICD-10 and also to a more current and extensive procedure classification. The HIPE Unit in the ESRI has been carrying out several projects to find the best possible clinical classification to meet the criteria required. These are to find an integrated, supported, international, and updateable diagnosis and procedure classification.

Prior to 2002, clinical data collected by the HIPE system consisted of one primary diagnosis and up to five (optional) secondary diagnoses and one principal procedure and up to three (optional) additional procedures where appropriate. Since January 2002, up to nine secondary diagnoses and up to nine additional procedures may be reported for each discharge. The approach to coding these data has changed five times since the inception of the system, and the coding schemes used may be summarised as follows:

  • 1969-1980
  • 1981-1989
  • 1990-1994
  • 1995-1998
  • 1999-present
  • ICD-8 for Diagnoses & OPCS1 Procedures classification
    ICD-9 for Diagnoses & OPCS Procedures classification
    ICD-9-CM (Oct '88) for both diagnoses and procedures
    ICD-9-CM (Oct '94) for both diagnoses and procedures
    ICD-9-CM (Oct '98) for both diagnoses and procedures

    In upgrading coding schemes for diagnoses and procedures in Ireland, the factors that have been considered important include the availability of an integrated coding scheme for diagnoses and procedures, which is regularly updated, facilitates international comparability, and provides for the availability of training and software support as required. Following a review of international systems available and with agreement and support from the Department of Health and Children, it was decided to proceed with a pilot study of the Australian modification of ICD-10 (ICD-10-AM) to assess the issues that might arise with regard to implementation and training if this classification was to be recommended for use in Ireland. The pilot study addressed a number of specific objectives, including the appropriateness of the ICD-10-AM classification to the Irish hospital setting and the acceptability of this classification for clinical coders in Irish hospitals.

    The pilot raised several issues that can be applied to HIPE now and would need to be addressed ahead of any update. These include c hart documentation and adherence to coding guidelines. With ICD-10-AM there will be a need for improvement of medical terminology as there are no medical annotations in the ICD-10-AM coding books or e-book. The issue of self-education and responsibility for developing one's own coding skills will now be vital for coders. The commitment of coders and HIPE/Casemix Co-ordinators (HCCs) to support data quality initiatives is vital to HIPE. The findings of the Pilot Study of ICD-10-AM found that this coding scheme could be used successfully by coders in Irish hospitals and was found to be acceptable to these coders .  

    Coding in Ireland

    There are 60 acute public hospitals and about 150 clinical coders in Ireland. A full-time clinical coder in Ireland is expected to code about 7000 discharges per year. HIPE receives almost a million discharges per year with represents about 95 percent coverage of all public inpatient and daycase activity. These data are exported by each hospital on a monthly basis to the HIPE Unit in the ESRI, which maintains the HIPE national file of hospital activity. Coders are trained by the HIPE unit in the ESRI. They come from the administration staff of the hospital and will usually have no formal medical training. Training for coders involves attendance at a three-day basic training course that covers all aspects of HIPE, including clinical coding, medical terminology, and training in the use of the HIPE data entry and reporting software. This course is followed up by a visit to their hospital by one of the data quality team. After three months these coders are invited to attend an intermediate level coding course.

    Specialized workshops are held three times a year and are recommended for all coders to continue their coding education. Following on from the pilot of ICD-10-AM, a nationwide series of refresher courses were held for all coders and their supervisors, the HIPE Casemix Co-ordinators (HCCs). These were two-day courses designed for experienced coders to refresh coding guidelines and remind coders of basic HIPE practice.

    The HIPE unit in the ESRI produces a quarterly newsletter called Coding Notes . This is the main communication tool for the HIPE Unit with the coders in the hospitals. Coding Notes is an integral and important part of HIPE. It informs Irish coders of new or amended guidelines, new codes, IT information, and provides help and guidance on all aspects of HIPE. It is used to notify coders and HCCs of developments in HIPE and of upcoming courses. It contains regular features on coding queries or issues that have arisen from audits or other data quality reviews.

    ICD-10-AM

    The Irish Department of Health and Children has approved ICD-10-AM as the Irish national standard beginning in January 2005, and this classification will supersede ICD-9-CM for morbidity coding in Ireland in HIPE as of January 1, 2005. All HIPE discharges from January 1, 2005, will be coded using ICD-10-AM. The W-HIPE software will accept the appropriate code for the discharge code entered.

    Work on the Tenth Revision of the ICD started in September 1983 with a meeting in Geneva. The programme of work was guided by regular meetings of Heads of WHO Collaborating Centres for Classification of Diseases. It has over 2000 categories, which is almost 900 more than are in place in ICD-9.

    An Australian version of ICD-9-CM was produced in July 1995. This was superseded in July 1998 by the development of ICD-10-AM, the Australian Modification of ICD-10 incorporating a procedure classification developed by the Australians. The fourth edition of ICD-10-AM will be introduced in Australia in July 2004 and this will be the edition adopted for use in Ireland in January 2005. There is no change in the structure between ICD-10 and ICD-10-AM. The meaning of the three-character and four-character codes in ICD-10 are not changed in ICD-10-AM, and any modifications are consistent with existing ICD-10 codes and conventions. The ability to compare ICD-10-AM data with ICD-10 data over time is not compromised. ICD-10-AM was developed by the National Centre for Classification in Health (NCCH), which is the centre of expertise for classification in all areas of health in Australia. During the development of ICD-10AM, the NCCH was advised by members of the NCCH Coding Standards Advisory Committee and the Clinical Coding and Classification Groups (CCCGs), consisting of expert clinical coders and clinicians nominated by the Australian Casemix Clinical Committee (ACCC).

    Changes for Coding

    While the adoption of the new classification will mean big changes in the codes assigned and in some of the guidelines applied, the extraction of data from charts will remain the same as will the selection of main terms and modifiers. The definition of the principal diagnosis remains the same, so experienced coders will still use the same basic skills while applying these with a new classification. There are differences also with the single volume coding book being replaced with the five-volume set and/or the e-book. Volumes 1 and 2 contain the diagnoses codes, which now begin with an alpha digit making them easily distinguishable from ICD-9 codes. The procedure codes in Volumes 3 and 4 are 7-digit codes for procedures presented in blocks. The fifth volume is the Australian coding standards. (ACS).

    The NCCH is responsible for developing rules and guidelines on how to apply and interpret the ICD-10-AM disease and procedure classifications when coding. An example of a guideline is ACS 0002 Additional Diagnoses.

    Secondary/Additional Diagnoses

    NCCH has tightened the definition of additional diagnoses to limit coding of conditions to only those that affect patient management in a significant way.

    An additional diagnosis should not be routinely coded just because a patient is regularly on medication for treatment of this condition. However, if the medication is altered or adjusted during the episode of care, the condition should be coded.

    Anaesthetics

    Anaesthetics are coded in ICD-10-AM. This is additional information not coded using ICD-9-CM. These anaesthetic codes require a two-character extension, which represents the patient's ASA (American Society of Anaesthesiologists) score. The first character of the two-character extension of the procedure code is the ASA score representing the patient's status at the time of the procedure. The second character of the extension represents whether a modifier of "E" is recorded on the anaesthetic form in addition to the ASA score. "E" signifies a procedure that is being performed as an emergency. This classification is shown in Box 5

    Box 5.

    American Society of Anaesthesiologists (ASA) Physical Status Classification

    First character


    ASA Class            Description
    1. A normal healthy patient
    2. A patient with mild systemic disease
    3. Patient with severe systemic disease that limits activity
    4. Patient with a severe systemic disease that is a constant threat to life
    5. A moribund patient who is not expected to survive longer than 24 hours without surgical intervention
    6. A declared brain-dead patient whose organs are being removed for donor purposes
    7. No documentation of ASA score

    Second character


    Emergency modifier      Character      Description
                    E                        0              procedure being performed as an emergency

                                              9              non-emergency or not known2

      Source: NCCH ICD-10-AM

    ACS-0042 Procedures Normally Not Coded

    Australian Coding Standard 0042 Procedures normally not coded lists procedures not coded because they are usually routine in nature, performed for most patients, and/or can occur multiple times during an episode.3 The reason for omitting these codes is that the resources used to perform these procedures are often reflected in the diagnosis or in an associated procedure. For example:

    • X-ray and application of plaster is expected with a diagnosis of Colles fracture
    • Intravenous antibiotics are expected with a diagnosis of septicaemia.

    Training for ICD-10-AM

    Experienced coders will continue to code as at present, using the chart as the source document, choosing the diagnoses and procedures, and selecting codes using first the alphabetical classification to identify main terms and modifiers and then verifying the codes in the tabular. The Australian Coding Standards contained in Volume 5 will provide clarification as appropriate. An Irish supplement to these Standards will be produced to complement Volume 5. This will address issues of relevance to Ireland and supplement areas of local interest.

    Introductory workshops will be held over the coming months. Training courses will be held in early 2005 to instruct on coding diagnoses, procedures, and the coding standards. There will also be instruction in the use of the e-book. All coders and HCCs will attend these courses and books, e-books, and relevant software will be distributed at this time.

    Preparing for ICD-10-AM

    Preparations are now well underway for the transition to ICD-10-AM. Hospitals were notified officially in March 2004 of the decision to change the classification to ICD-10-AM beginning in January 2005. The three members of the HIPE Unit at the ESRI involved in clinical coding traveled to the NCCH, in Sydney, Australia in May 2004. They spent one week at the NCCH participating in both training in ICD-10-AM (4 th Edition) and "Train the Trainer" sessions facilitated by NCCH trainers. The NCCH also arranged hospital visits, which afforded the Irish team the opportunity to experience ICD-10-AM "at work." Through these visits to both public and private hospitals in Sydney, the Irish team met with Australian coders and HIM professionals.

    They also traveled to Brisbane to attend two of the NCCH "Updating to 4 th Edition" workshops. These workshops are for one day and are held throughout Australia before an update to inform clinical coders of changes in the classification between editions. There were also Web-based education modules available, which attendees complete prior to attendance at these workshops. The Irish team had completed these before the workshops in Brisbane. These workshops proved useful regarding the updates to the 4 th edition, further training in the classification, and exposure to NCCH workshops and coders. This experience afforded the Irish team the opportunity to further evaluate the best options for the workshops to be held in Ireland.

    Information on the implementation, upcoming course information, and articles on different aspects of ICD-10-AM are published in Coding Notes , the quarterly newsletter the HIPE Unit. The HIPE Unit in the ESRI provides hospitals with the classification, training, and related materials free of charge to participating hospitals. As soon as the books become available, the HIPE Unit hopes to provide at least one set to each coding department in the country to enable coders to become familiar with ICD10-AM.

    The introduction of the classification will take place in several phases. Phase 1 will take place during the second six months of 2004. A series of two-day education workshops are being held throughout Ireland to inform all relevant personnel of the changeover to ICD-10-AM. At these workshops, the Irish team informs attendees of the reason for the change and details of the classification, and highlights stages in the implementation process and issues to be considered in the lead up to the changeover from ICD-9-CM. Training will be given by specialty and will cover diagnoses, procedures, and standards as appropriate. Training will also be given in the use of the ICD-10-AM e-book.

    Phase 2 of the training of the coders in Ireland will be facilitated by two members of NCCH who will travel to Ireland in January 2005. There will be a series of nationwide workshops held at this time to educate all coders and HCCs in ICD-10-AM. This Phase 2 training in early 2005 will consolidate the training from Phase 1. Post implementation workshops will be held throughout 2005 to further complement the training presented in the previous months.

    Hospitals are advised to prepare for the changeover to make it as smooth as possible. They have been encouraged to use this as an opportunity to improve chart documentation. Everyone involved with HIPE, hospital records, and documentation, including clinicians need to be informed and involved in the changeover. ICD-10-AM is an excellent classification, which will work best with optimized chart documentation. Hospitals have been informed about "The Good Documentation Guide" available from the NCCH to help with improving their medical records in advance of the implementation. Coders will need to educate themselves using The "Ten Commandments" currently published on a quarterly basis in Coding Matters. The "Ten Commandments" are also incorporated into, and accessible through, the e-book. Coders will be encouraged to gain a thorough knowledge of the classification and to use of the Australian Coding Standards.

    Irish hospitals are being advised to clear coding backlogs to cut down on the dual coding period, when coders will use both classifications depending on the year of discharge of the case being coded. Hospitals are currently expected to return coded cases within three months of the patient's discharge. It has been recommended to hospitals that they stabilize the staffing situation in the coding department as much as possible. Some hospitals have decided to let some coders continue to code in ICD-9-CM to facilitate single classification coding. These coders remaining with ICD-9-CM may be scheduled to leave coding in the coming year or may feel more confident to adopt ICD-10-AM when the rest of their team has experience with coding in the new classification.

    It is recommended that each hospital appoint a "10" Team leader within the coding department. This will be a coder to organize and motivate the coding team through the changeover. Hospitals are advised to identify the departments and key staff members throughout the hospital that need to be aware of the transition to ICD-10-AM and to form an implementation team. This group should include representatives from the coding department, the IT department and from the medical staff. Above all, hospitals are being encouraged to talk about ICD-10-AM in the hospital.

    Coded data is collected in standardized software, written and developed by the IT section of the HIPE Unit in the ESRI. The IT group will be adapting this software to enable the input of ICD-10-AM codes for all cases with a discharge date on or after 1.1.2005. There are currently edits in place to ensure high standards of quality in the data collected and input to the system. These edits are being adapted and mapped where possible to continue this important practice of maintaining high quality data input at hospital level.

    This is a good move forward for coding in Ireland, a positive change that will succeed through co-operation and the working together of all stakeholders in HIPE. The coming year will be one of the most exciting for all those involved in clinical coding in Ireland since its inception in 1971. With the cooperation of the HIPE Unit, ESRI, the Department of Health and Children, the clinical coders, and their HCCs, Ireland will emerge with a robust, comprehensive, and even better hospital data collection system.

    Endnotes

    1. Office of Population Censuses and Surveys (OPCS) Classification of Surgical Operations, Second Edition, 1975. London.
    2. Extracted from NCCH ICD-10-AM, July 2002, "Procedures."
    3. Extracted from NCCH ICD-10-AM, July 2002, Australian Coding Standard 0042.

    Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004