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Results Conversion to ICD-10 did not significantly impact payments per visit ($306.56±$56.50 vs $321.43±$38.12, P=0.42), relative value units per visit (7.15±0.56 vs 7.13±0.84, P=0.95), mean volume of visits (1,887.08±375.02 vs 1,863.83±189.81, P=0.71), or percentage of high-level visits (29.7%±4.9%, 548 of 1,881 vs 30.0%±1.7%, 558 of 1,864, P=0.81). For every 100 visits, the number of coding-related denials increased from 0.98±0.60 to 1.84±0.31 ( P. Introduction The conversion from the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) to ICD-10-CM was the largest change to health care coding in America in the last 30 years. While ICD-10 was approved in 1990 and had been utilized in several countries since as early as 1994, its use only became required in the United States on October 1, 2015. The version used in the United States has several significant modifications suggested during an open comment period and via a field test performed by The American Hospital Association and the American Health Information Management Association.

ICD-10-CM, as the version is known, added many more codes than the original World Health Organization version used prior to adoption in the United States., The Department of Health and Human Services originally planned to instate ICD-10 on October 1, 2011, but its implementation met resistance. The American Medical Association feared that the costs of implementing ICD-10 would be extreme and could even put smaller practices out of business. In 2009, the Department of Health and Human Services changed the date to October 1, 2013. Two additional delays led to the final implementation date of October 1, 2015. Each ICD-10 code has space for seven characters, an increase from the five available in ICD-9. The nearly 70,000 diagnostic codes available in ICD-10 provide a much greater level of detail than the 14,500 codes available in ICD-9, and mapping diagnoses from one to the other is often convoluted and rarely straightforward.

Included in the increased details are codes that specify laterality and severity of disease, features that have a substantial effect on coding in ophthalmology. Materials and methods We performed a retrospective database study of deidentified billing records at the University of California (UC), Davis Eye Center in Sacramento, CA. The study protocol followed the tenets of the Declaration of Helsinki and was exempted from approval by the university’s Institutional Review Board Committee as the work was not considered human subject research as defined by federal regulation 45 CFR 46.102. Our practice consisted of 16 ophthalmologists and included specialists in cornea, glaucoma, neuro-ophthalmology, oculoplastics, pediatrics, and retina. Optometrists, ophthalmology trainees, and part-time volunteer clinical faculty were not included in the analysis.

Over the 2 years of the study, the medical staff was unchanged with the exception of the following: 1) a comprehensive ophthalmologist was on sabbatical and worked only part time before June 2015; 2) a neuro-ophthalmologist left the practice in 2015 and was immediately replaced by another neuro-ophthalmologist who saw fewer patients each month; and 3) a retina specialist was hired into the practice 2 months after the beginning of the study period. These three providers were excluded from the analysis to avoid the confounding effect of changes in their clinical volume. ICD-10 implementation strategy In our practice, a team of ophthalmic coding specialists reviews and analyzes all patient charts after visits are completed and assigns the coding information for medical billing. From July 1, 2014, until the official implementation of ICD-10, the coders utilized both ICD-9 and ICD-10 codes for additional training. The coding staff remained unchanged throughout the course of the study period, and no additional compensation was provided to the coders during the transition period. These figures do not include the cost of software implementation to the EHR system, which took place across the university medical center prior to ICD-10 implementation. Financial and clinical impacts To analyze the changes in clinical revenue and productivity after ICD-10 conversion, we obtained billing summaries from the UC Davis Eye Center from October 1, 2014, to September 30, 2016, and examined the mean payments per visit, relative value units (RVUs) per visit, number of visits, and percentage of high-level visits for each month during the 12-month periods before and after ICD-10 implementation on October 1, 2015.