The Code Making Process

The Code Making Process

Page 26

The Code Making Process:

creating codes

What Every Coder Should Know

The proposed coding changes or additions to the ICD-9-CM presented at the ICD-9-CM Coordination and Maintenance (C&M) Committee meetings were reported in a regular column in ADVANCE for several years. This was an effort to provide coding colleagues with information about the changes under consideration and to elicit their input as to the soundness/necessity of the proposed modifications.

Over time, however, an awareness has emerged that many colleagues are not fully informed about the actual code making process. Upon learning recently that a statement was made that the World Health Organization (WHO) is responsible for the quarterly coding guideline updates in Coding Clinic, it was obvious the time had come for this article.

In 1985, the ICD-9-CM C&M Committee, a federal interdepartmental committee, was formed and charged with the mission of maintaining and updating the ICD-9-CM. That mission includes approving coding changes and developing errata, addenda and other modifications to the ICD-9-CM to reflect newly developed procedures and technologies and newly identified diseases. The Committee is also responsible for promoting the use of federal and non-federal educational programs and other communication techniques with a view toward standardizing coding applications and upgrading the quality of the classification system.

The C&M Committee, co-chaired by the National Center for Health Statistics (NCHS) and the Health Care Financing Administration (HCFA), provides an open public forum where requests for modifications to the ICD-9-CM can be presented and discussed. The NCHS has responsibility for maintaining the diagnosis codes (Vols. I & II: the Diagnosis Alphabetic Index and Tabular List) of the classification. Maintenance of the procedure codes (Vol. III: the Procedure Alphabetic Index and Tabular List) is the responsibility of HCFA. (The procedure volume of the ICD-9-CM is not part of the WHO’s official ICD-9 and, therefore, is not subject to the same modification constraints as those that apply to diagnoses.)

Modifying the ICD-9-CM
Modifying the ICD-9-CM is not taken lightly: changes should alter the classification as little as possible. Any request should be significant–that is, it should meet a demonstrated need by users and be supported by the coding community. Finally, a modification must be clinically correct and be accepted by the medical community.

There are four basic acceptable reasons to consider modifying the classification:

  • Typographic errors
  • Outdated code assignment due to advances in medical knowledge
  • Identification of a new disease; and/or
  • A current code is too general or lacks needed specificity.

International agreements between the WHO and the world community regarding the use of the ICD-9 are such that any modification has to adhere to basic ICD-9 principles:

  • Modifications should follow the format of the ICD-9.
  • The content of a three-digit code should not be changed.
  • Any modification should be consistent with existing codes.
  • The ability to compare data over time should not be compromised.

Requesting a Modification
The C&M Committee encourages participation in the modification process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA) and the American Hospital Association (AHA), and various physician specialty groups as well as other health care industry members (see sidebar on page 28), health information management (HIM) professionals, and other members of the public to contribute ideas on coding matters.

The coding issue should be defined in detail prior to making the request to the NCHS or HCFA for a change or addition. Does the issue fit the criteria for modification? Or, is the problem one with information needed for data collection forms, a lack of knowledge of the use of the classification, or a need for information specific only to a unique situation?

A code is usually limited to defining elements of a disease or an encounter for health care, not a patient. This distinction is fundamental. The NCHS and HCFA are available to assist ICD-9-CM users in determining the soundness of the modification request.

All requests are reviewed thoroughly by the committee staff. Those requests that meet the criteria for modification are placed on the agenda for the next meeting. However, presentation of a coding request at a C&M meeting is not a guarantee the request will be approved, only that it will be considered.

The ICD-9-CM C&M Committee Meetings
The Committee presents proposals for coding changes/additions at public meetings held twice a year. The meetings are at the HCFA complex in Baltimore and are typically one-day long. The first meeting occurs in May and the second in November, for consideration of coding issues for implementation in the fiscal period starting October of the following year. Approximately one month prior to the meeting, an agenda is posted on the two agencies’ Web home pages: and www

After the attendees at the meeting are welcomed by the HCFA co-chair, they are asked to introduce themselves. Announcements are made and then the procedure topics are discussed. These are often presented by physicians or representatives from various interested organizations and they provide interesting educational opportunities.

For example, several years ago, when left ventriculectomies were just emerging, literally from the Brazilian jungle, a surgeon gave a presentation on his trip to Dr. Batista’s clinic to learn about the procedure. Much controversy had followed in this country because of the lack of data–many of Dr. Batista’s patients were natives who were lost to follow-up when they returned to the jungle. The presenting surgeon was requesting a distinct code for left ventriculectomies so the procedure could be tracked specifically in this country.

After each presentation, the attendees are invited to comment on the request. Presen-tation of proposed diagnosis changes or additions follows.

Summaries of the diagnosis and procedure topics are available on the Internet at the two agencies’ home pages. After considering the opinions expressed both at the public meetings and in writing within the 60-day comment period following the November meeting, the Committee formulates recommendations and submits them to the Director of the NCHS and the Administrator of HCFA, who have the final authority to approve changes.

Interesting to note is the fact that the present classification is running out of available code numbers in certain categories, especially on the procedure side, with technology changing so rapidly and the desire to be able to track more disorders/diseases and procedures specifically. In the last several years, we have seen an increase in diagnosis code expansion, but the procedure codes offer less opportunity for creating new code numbers. The ICD-10-CM and ICD-10-PCS (Procedural Classification System) will provide limitless code possibilities so this situation will not arise again.

The Four Cooperating Parties and the Coding Clinic
Official coding guideline policy is formulated in this country by the four Cooperating Parties: AHA, AHIMA, NCHS and HCFA. Representatives from these organizations meet quarterly, along with members of the Editorial Advisory Board (EAB) of the Coding Clinic for ICD-9-CM, to discuss questions or topics that have been submitted to the AHA’s Central Office for ICD-9-CM for clarification or a guideline. The answers have to be agreed to unanimously by the four Cooperating Parties. This accomplished, they are then published quarterly in the Coding Clinic. The WHO has no input into this process.

It is hoped this article has provided information each medical record coder and other HIM professional should have about one of the basic tools of the profession, the code numbers.

June M. Laing, a health care consultant, is a manager with Cap Gemini Ernst & Young U.S. LLC and is based in the Atlanta office.