ICD-10 and Urologic Oncology: A Disappointing Combination

The 12 month countdown to the adoption of ICD-10 has begun.

Leonard G. Gomella, MD

Chairman Department of Urology

Associate Director Sidney Kimmel Cancer Center

Thomas Jefferson University

Philadelphia, Pennsylvania

leonard.gomella@jefferson.edu

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 US 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. ICD-10 system is not new and has been in existence for nearly 20 years.

How much input did medical specialists have 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 cancer. Localized pancreatic and breast cancer get 9 primary codes in ICD-10 based on location of the malignancy. Only one code 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 vs 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 US 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 as soon a 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 the American Health Information Management Association, advocates, early testing participants and perhaps most importantly business benefactors in the ICD-10 adoption: “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”.

Over 80 provider organizations including the AMA and other associations failed in their attempt to stop implementation of the ICD-10. There is significant concern that the excessive governmental regulatory changes imposed over the last couple of years are already creating challenges in delivering patient care. Providers, practices, and hospitals continue to struggle with requirements of the Affordable Care Act, ePrescribing, and EHR adoption. Sadly, the costs of this Centers for Medicare & Medicaid Services (CMS) mandate including computer, EHR, and billing system upgrades as well as the costs of staff training are completely at the expense of the providers and their practices. It has been estimated by the AMA that on average a small practice can spend up to $226, 105 with larger practices and health systems spending millions in the ICD-10 conversion. It is sad to think that even in practices that are fully prepared for the transition have been warned to be prepared for reimbursement delays and financial hardship beyond the costs of the implementation.

The stated goals of ICD-10 are to more accurately classify diseases, treatments, complications, quality outcomes, and improve public healthcare. The benefit to patients and their oncology related providers is not clear for some very common oncologic conditions such as prostate and kidney cancer. There are well recognized and important clinical differences in properly classifying patients with these malignancies. As this appears to be how reimbursements and outcomes will be measured in the future, the failure of ICD-10 to capture essential elements of localized prostate and kidney cancer is very concerning. The applicability of this governmentally mandated ICD-10 dataset as a metric for any such analysis may not be accurate.