Editor’s note: Buried in its nearly 1,700-page proposed rule on fiscal year 2015 inpatient payment policies released on April 30, the Centers for Medicare & Medicaid Services included some language that sets Oct. 1, 2015, as the new ICD-10 implementation deadline. President Obama signed Medicare legislation a month earlier giving physician practices an extra year to make the transition from ICD-9 to ICD-10 procedure codes, but CMS got the clock ticking once again for practices to make the transition.

The switch means that health care providers and insurers will have to change out about 14,000 codes for about 69,000 codes. Some of those changes will impact nephrology. We include two articles in this section on how to get ready.


If you were a physician practicing in 1900, and wanted to note a diagnosis, a citation could be made from the International List of Causes of Death (ILCD) Revision 1. In that original list there were 191 disease conditions; only two of those options were kidney focused.

Throughout the years, the classification system has evolved from ILCD, which was a relatively small list of causes of mortality, to ICD, which is a complex and detailed organization of codes that today support medical reimbursement.1 The current ICD-9-CM list contains about 13,000 codes, approximately 136 of which are renal-specific.

Now we move into the era of ICD-10, where the number of codes rises to over 72,000. The transition of ICD-9 to ICD-10 has been delayed until October 2015, but it still looms on the horizon. Many providers believe that their EHR will easily “flip the switch” and make the ICD-10 change simple. Although the use of an EHR can be a powerful tool in helping clinicians select ICD-10 codes, the EHR alone will not be the saving grace when October 1 rolls around.

Adding another layer of complexity is the reality that some computer systems integrate the problem list with the billing component. Clinical problems are often described with SNOMED (more on this later) CT codes and billing is driven from ICD codes. This increased complexity will certainly be felt by providers, and the higher level of detail found in ICD-10 may require more detailed documentation (see Figure 1).

We recently asked several nephrologists to describe their top concerns regarding ICD-10. The responses across our large customer base were similar and are articulated well by nephrologist Peter Manring:

  • The new codes required will be unfamiliar.
  • Physicians will have to be much more specific in documenting patient problems.
  • Documentation will need to support the added specificity of the billing codes.

Let us look at each of these concerns a bit more closely.

 The EHR will just replace the ICD-9 codes with the ICD-10 codes, right?

The first concern is unfamiliarity with the new codes. One nephrologist stated, “For the most part, I have memorized the top 30 or so codes I use on a daily basis. When searching for problems to add to my problem list, it is often faster to search by the ICD-9 code than to type in the term.” Many providers have committed these common ICD-9 codes to memory and may know the ICD-9 number as well as, if not better than, the description.

This dynamic will change in the new world of ICD-10. The new code set is far more complex, the characters are completely different, and it will take time for providers to develop the same fluency they enjoy today.

Some physicians may think that their EHR systems will just simply replace ICD-9 codes with ICD-10 codes. While technology can assist with the conversion, a clinical review may still be required. The EHR can also provide easy-to-use ICD-10 search tools with robust term-based queries that quickly drill down to a manageable selection list. With more than 70,000 ICD-10 codes to choose from, it will be important for technology to assist the provider in making proper selections in a fast paced patient care environment. This can be accomplished by utilizing mapping tools that help the provider transition current ICD-9 codes to the correct new ICD-10 codes.

Related: Billing for ICD-10: Be prepared

The second stated concern is the new level of specificity that will be required for some diagnoses. Some clinicians may believe the new process will go something like the following: the clinician will search by familiar ICD-9 codes, the EHR may automatically map to an ICD-10 code, and if this is not the correct selection, certified coding personnel will make the needed corrections. This may sound good in theory, but this method could limit the provider from making a more specific ICD-10 selection supporting their documentation. Take the following scenario as an example:

  • A patient is seen and presents with gout in the right foot
  • The provider notates this in the patient’s progress note
  • Next, the provider searches for the all-to-familiar ICD-9 code 274.9 (gout, unspecified) which the EHR automatically maps to the ICD-10 code M10.9 (gout, unspecified)
  • The unspecified code for gout is applied to the patient’s bill.

In the above scenario, the patient’s progress note is the only place that defines the actual site of the gout. In this example M10.9 would not be coding to the highest specificity. The more appropriate action would have been selecting the more specific ICD-10 code of M10.371 (Gout due to renal impairment of the right ankle or foot) when notating the patient’s problem. EHR systems that can help providers view and select quickly from a manageable list of specific ICD-10 codes can ease the burden on the provider.

A more granular code selection is the third area of concern. Ensuring that documentation supports billing is not a new concept but the specificity which ICD-10 brings to the table will require more detailed documentation to support the diagnosis. Selecting the more specific code up front can reduce the confusion between documentation and what is on the claim.

Let us examine the gout example again. Today a provider might bill for unspecified gout and simply mention this condition in a general term in their documentation. If this provider selects the appropriate specific code of M10.371 for gout related to renal impairment, then the clinical documentation must substantiate that the gout is renal related. Providers have learned over time many of the nuances of billing and what degree of documentation is required to support billing. With the transition to ICD-10, there will be greater focus on ensuring the clinical documentation supports the diagnosis or diagnoses submitted on the claim.

Important lesson: Avoid code steering

One action that should not be taken by EHR systems is code steering. Systems should not suggest or steer the decisions of providers in regards to billing. Providers should document the pertinent clinical findings and bill based off that documentation. In an effort to gauge accuracy of documentation and billing practices, many nephrology groups are conducting chart audits. Results obtained from a review of documentation, coding and billing, can provide valuable feedback to the provider.


If the transition from ICD-9 to ICD-10 is not enough to keep you up late at night, there is other new terminology on the market to complicate matters. As noted earlier, SNOMED (Systematized Nomenclature of Medicine) is the required terminology language for denoting patient medical problems on a codified problem list. Meaningful Use introduced SNOMED into many E H R  systems.Up until recently, ICD-9 has been the sole vocabulary for a patient’s problem list and billing diagnosis. Many providers may have been surprised to hear that Meaningful Use required a patient’s problem list to be codified using SNOMED. With all the hype from CMS to switch over to ICD-10, one might expect ICD-10 to be the required terminology for diagnosis. SNOMED is a knowledge-based ontology for clinical documentation and decision-making purposes, whereas ICD-10 is a hierarchical classification system for billing and administrative purposes.

Keeping up with two vocabularies concurrently may sound like a daunting task, but many EHRs offer mapping between the SNOMED CT problem and the ICD-10 billing diagnosis. In fact, codifying a problem list using the more granular/descriptive SNOMED code can make the transition to ICD-10 easier than mapping between ICD-9 and ICD-10.


The ICD-10 transition will be an evolutionary process. Relying on the EHR or certified coding staff alone will not be sufficient. The EHR can facilitate easy search tools that assist the provider in selecting a diagnosis. Billing staff are an invaluable resource to help validate that coding and documentation are in sync but the burden will clearly rest on the provider. The provider will be juggling a new code structure, drilling down to new levels of complexity and ensuring their documentation supports the specificity of the new codes selected all while managing a full patient schedule. Education for the provider will be of paramount importance as they navigate this brave new world.


Moriyama IM, Loy RM, Robb-Smith AHT. History of the statistical classification of diseases and causes of death. Rosenberg HM, Hoyert DL, eds. Hyattsville, MD: National Center for Health Statistics. 2011.