YNHHS to change diagnosis codes used in patient records

Health Information Management employees Kerry Kane (left), inpatient coding specialist, and Tara Eisenstein, inpatient coding supervisor, consult an ICD-10 book listing some of the many new codes that will be used in patients' medical records.
Health Information Management employees Kerry Kane (left), inpatient coding specialist, and Tara Eisenstein, inpatient coding supervisor, consult an ICD-10 book listing some of the many new codes that will be used in patients' medical records.

Over the next year, Yale New Haven Health System will begin using new codes in patient health records that are more specific about a patient's diagnosis.

The federal government is requiring the transition from ICD-9 codes, used nationwide since 1979, to the new ICD-10 codes. ICD codes are used in patients' medical records to indicate diseases, signs and symptoms, abnormal findings and other information. Because ICD-10 codes are more specific, the number of codes healthcare providers use will increase from around 14,000 to about 70,000.

All physicians throughout the health system and Northeast Medical Group, as well as Yale Medical Group, will be trained in 2014. Health Information Management (HIM) coding professionals will receive additional training, while other YNHHS employees will receive more general training and information. The ICD- 10 conversion will also require changes to Epic and 40 other information technology systems.

Hospitals and other healthcare organizations that do not implement the new ICD-10 codes by Oct. 1, 2014 will not receive reimbursement for the care they provide from the government, insurance companies and other private payers.

"This is a major project that will require a lot of work by physicians and many hospital employees in different departments," said Cindy Zak, director of HIM and Coding. "But by using more specific codes in patients' records, we will enhance the safety and quality of the care we provide and help ensure the hospital is properly reimbursed for that care."

The project will involve 12 multidisciplinary, systemwide subcommittees to help guide project development, implementation, training and communication over the coming year. Additional communications about this project, including training schedules, will be available in the coming weeks.