Reasoning around moving to ICD10 and our subset of it
This article explains our choice of ICD10 as a coding schema and of the subset of codes we include.
Why are we moving to a new diagnostic coding schema?
Our old diagnosis list was made in-house designed mostly for the Critical Care setting where our database started out. We are moving to a new diagnosis set primarily to make our data set more comparable to other data sets, and to include more diagnoses that are relevant to Internal Medicine physicians outside of the ICU setting.
Why are we moving to ICD10 rather than a different coding schema?
ICD10 is one of the most widely used diagnosis coding standards. Among others, our hospitals' medical records departments use it. Using the same system as used elsewhere means that diagnoses don't need to be translated to another system, where often a 1-to-1 translation is not possible. It also means that our definitions are more likely to be equivalent to those used by other data sets.
Another benefit of moving to ICD10 will be that it should eliminate diagnoses for which we don't have a code, since ICD10 includes codes for diagnoses that have no specific code.
Why are we including the subset of diagnoses that we do
We are seeing increased interest by Internal Medicine physicians in our data set. Since they fund our program to a large extent, we need to make sure our data includes what they are interested in, in a format that is usable for them.
Why do we not include the entire set of ICD10 codes
The full ICD10 includes over 16000 diagnosis codes. We decided to only use a subset of this to make it easier to learn the new list. Any diagnoses whose codes we omitted can be assigned to the next more general NOS code.
Should we remove some?
Template:Discuss@task Laura is working on a list of dxs we might want to remove. Please put here when ready. (emailed Laura Ttenbergen 16:15, 2017 November 6 (CST))
- suggested we remove the following:
- sunburn,
- alopecia,
- albinism,
- disorder of the nail.--LKolesar 07:30, 2017 November 7 (CST)
Concerns
Do we really compare our data to other data sets
- What is the rationale for converting to the ICD10 system? Is it so that we can compare data to a universal system? How much is this going to be done and how will this bring value to our database?
- I want to propose that other alternatives exist. Another idea would be to fix our old system to include the list we already have of codes that are missing...
- That would not make it any more comparable to other data sets.
- ... and organizing it properly. I see major problems with the ICD10 system for ease of entry and even the list itself is not user-friendly or system-based.
- Julie will also have major difficulty deriving clear information from the ICD 10 and especially the CCI system.
- Julie is fully involved in our move over to the new system, we will make sure she gets what she needs.
- I am currently working on a list of problems with both of these structures. Would appreciate feedback from collectors now that they are looking at ICD10 and CCI and trying to use them. -LKolesar 12:48, 2017 December 13 (CST)
- Please put your problems on the wiki as they come up. That way we can start working on them rather than wait until you have a final list you are ready to bring forward. Also, other sites can know which concerns have already been expressed, so they don't need to re-hash things separately. Ttenbergen 16:22, 2017 December 23 (CST)/--Trish Ostryzniuk 11:03, 2017 December 24 (CST)
Problems seen with ICD 10 as of December 2017
Template:Discussion ICD 10 Diagnosis review: (Laura Kolesar) Dec 8, 2017
Goals for our database should be: Data must be easily, efficiently and consistently entered. The data must be readily identifiable to retrieve for statistical purposes. The data must meet the needs of most users of the data.
- The idea to look on the wiki when trying to determine the best code is not an efficient system and wifi is not available at all times in all locations.
- Have all the people who use the database been given a list of the new codes and examples of the CCI codes to see if this data is sufficient for what they need?
Some issues with ICD 10:
I started writing a list of potential issues. This list is just the beginning and is in no way complete or thorough.
Pathogen issues
- Streptococcus: have Groups A, B, D, G but would need to list the names in each group for accurate data collection.
- Klebsiella: only have K.pneumoniae, not K. Oxytoca
- Serratia: no sub categories
- Candida: no sub categories
- Enterococcus: no sub categories
- Citrobacter: not in list
- Enterobacter: not in list
- Stenotrophomonas: not in list
- Acinetobacter: not in list
- No negative culture option
- We need to be quite specific in our database in order to properly code VAP criteria, CLI etc. I don’t think the pathogen list for bacteria is extensive enough. No mixed option so would need to put in each pathogen separately.
Is Dr Kumar OK with this list?
Diagnosis issues
- Hospital acquired pneumonia. No pneumonia in the iatrogenic codes at all. Could put 3 combined codes: pneumonia, bacterial, the pathogen code, Iatrogenic problem NOS related to surgery or procedure but this is not necessarily true.
- Ruptured chordae tendinae
- Vasculitis: only options are limited to skin, NOS or necrotizing vasculopthy/vasculitis NOS
- Wegener’s is on list but Sjogruns syndrome is not
- Aneurysm in aorta: does not differentiate between abdominal and thoracic aorta.
- No option for dissection of aortic aneurysm (only arterial aneurysm or dissection NOS) Dr Manji wants to have the dissection of aortic aneurysms and the differentiation of abdominal and thoracic included.
- Right heart failure ( just cor pulmonale listed)
- No acute renal insufficiency code: can use ATN or “renal tubular disorder NOS” or “kidney or ureter disorder, NOS”, or “Kidney , infarction or ischemia” so many options, it may be inconsistently coded. Often the reason for the issue is not known right away. We do have a very general code: “Kidney, renal failure/insufficiency/uremia, unspecified as acute or chronic”. How helpful would that code be?
Have the renal doctors who use our database seen the options for their codes? Is this the list they want?
- Intra-abdominal abscess: only options are intestine, anus, liver, peritonitis. No pancreatic abscess (do have pancreatitis and pseudocyst).
- Retroperitoneal hemorrhage or abscess not in list. Have “retroperitoneal area, diagnostic imaging abnormal”
- Does not differentiate between witnessed or unwitnessed arrest.
- Isolation is on the tiss and in tasks, do we need to include this in the diagnosis list?
- There is a risk of data collectors putting in a code like seizures NOS and then not combining it with the cause. Will this be a problem for our database to lose the cause of some diagnosis?
- Are there going to be set guidelines (numeric limits) for the metabolic derangements like hyper or hypo kalemia, natremia, etc. like we have now?
- (This issue has been resolved: all electrolyte issues can be coded if they are being treated effective Feb12, 2018.)
- Falls are captured by the mechanism of injury in ICD10. Do you want to capture falls where there is no obvious injury? If so, how do we do this?
- When coding septic shock, should we put in the organ damage issues connected to the septic shock code with the same priority number? ie. liver problems, renal problems related the the shock? If we don't do this we don't really have a shock liver code so with the current list there is nothing to show this link. Just need to clarify this. It is tricky because there can be multiple causes of organ damage even in the same patient.--LKolesar 13:26, 2018 February 8 (CST)
Comorbid discussion
- GFR is not readily available to use for the categorization of Chronic Kidney disease STAGES 1-5. I do not see it listed in the EPR labs. Is there an easy place to find this? They sometimes comment upon the stage or the GFR in the progress notes but this is not the ideal place to find this information. I think it is only done once a Nephrology consult is done. It is easy to miss comments in the notes. It is time consuming to find the Stage using this parameter.
- Need to add the GFR for each stage (chronic kidney disease stages 1-5) right into the ICD list so we don't have to look it up every time!--LKolesar 11:54, 2018 February 13 (CST)
- We currently put in a level of severity in our comorbids. Ie COPD- mild, mod or severe. Is it OK to not have this information? Without the severe designation we may miss the chronic history component of apache (severe liver, lung, etc.)
- Are all previous conditions being put in this list? If so, this is a significant increase in numbers of codes required.
- How is chronic drug abuse put in comorbids if we don’t know the specific drug type? ICD10 requires the specific drug type.
- Do we need methamphetamine added?
- ( I recently had this on one of my patients and I ended up using psychoactive substance NOS, chronic abuse/dependence/addiction. When I googled meth, it came up as a psychoactive drug.)--LKolesar 11:52, 2018 February 13 (CST)
- HIV infection, asymptomatic is listed in the categories but will not come up in the dropdown list.
- There does not seem to be a "NO COMORBID" option in the list.
- Peripheral vascular disease is listed but does not enter or come up in a search.