September 9, 2015

New Codes Tell Patient Stories

A good storyteller understands that it’s all in the details. It is the details that convey the essence of the story. In the world of coding, capturing all the necessary details is critical to accurately communicate and report the documentation in the medical record – in other words, to convey a patient’s story.

On October 1, 2015 the Centers for Medicare and Medicaid Services is scheduled to implement ICD-10 CM (diagnoses) and ICD-10-PCS (inpatient procedures), replacing the ICD-9 CM diagnosis and procedure code sets currently in use in the United States.

All providers in EVERY HEATH CARE SETTING will use ICD-10-CM diagnoses codes.

ICD-10PCS procedure codes will be used only for hospital claims for inpatient hospital procedures.

A number of countries have already moved to ICD-10 including:

United Kingdom (1995)
France (1997)
Australia (1998)
Germany (2000)
Canada (2001)

The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine.

The current system ICD-9-CM is 30 years old and contains outdated and obsolete terminology. It cannot accurately describe the diagnoses and inpatient procedures of care delivered in the 21st century. The current coding system has 14,315 diagnosis codes and the new system has 69,368 diagnosis codes. The change in the number of codes is an unprecedented magnitude.

This new coding classification system will impact many areas of our facility, including physicians, therapists, case managers, patients, IT, coding professionals and patient financial services, to name a few. Strategic planning began a year ago for this major transition to ICD-10. Communication as well as education and training is necessary for success as we prepare to launch.

Documentation of the details of the patient’s story will be necessary to ensure a successful implementation. We will be ready for October 1, 2015.


Janet Murgittroyd, RHIA, CCS
Director, Medical Records