Back in Part 1 of our ICD-10 series on Perspectives, I mentioned that I would dedicate my final post to discussing the ICD-10 "implementation controversy." I didn't guess at the time that it would take an act of Congress to halt that implementation! (I did expect a delay, but of the more top-down sort from HHS or the executive branch.)
HR43-02 delays ICD-10 until "after" Oct. 1, 2015, leaving its arrival date open-ended. To me, this does not bode well for implementation. A Congress that can put a Band-Aid on the sustainable growth rate fix for 17 years can also delay ICD-10 indefinitely.
In my view, an indefinite delay in ICD-10 will be unfortunate for all stakeholders, especially healthcare providers.
Reaction to the delay pretty much depended on which side of the Acute Care Continuum a stakeholder was on.
My industry, which I'll loosely define as healthcare information management (HIM), was generally disappointed. Thousands of documentation and coding personnel and their employers had invested thousands of dollars in training with a fall 2014 implementation date in mind.
The two major organizations representing the HIM industry responded quickly with open letters to their members in an effort to ease anxiety and anger. AAPC offered free brush-up courses for those who had already been trained and certified in ICD-10. Both organizations took the optimistic position that this was probably a one-year delay and encouraged members to continue preparing for ICD-10.
I wish I were as confident, but Congress' inability to resolve the SGR payment issue does not give me hope for ICD-10.
There were mixed responses from the other stakeholders, such as IT/EMR companies and payers. This sector was a very mixed bag in terms of readiness for a 2014 implementation, although some companies were ready and had spent millions to prepare.
And of course, the American Medical Association (AMA) had actively lobbied for the delay. Members had very real concerns about the cost of ICD-10 on small-to-medium size practices and the preparedness of systems vendors and payers.
But an unintended consequence of the delay is that it will now cost billions more from all segments of the Acute Care Continuum. And in our revenue-challenged healthcare system, billions for a system that may never be implemented is unconscionable.
Overcoming ICD-10 Myths and Objections
Prior to beginning this series, I had a passing knowledge of ICD-10. I probably had 50 to 75 ICD-9 codes memorized, as did many in my industry who have spent many years coding and auditing.
With the expected rollout of ICD-10, those codes imprinted on my brain would be rendered worthless come Oct. 1. I was apprehensive about transitioning to a new system with 70,000 codes. And I wasn't thrilled about the new format with its letters, numbers and placeholders.
Then I began to learn ICD-10 in detail. I found that some of my objections (and those of the larger industry) weren't grounded in fact. For example:
ICD-10 is too difficult to learn. When I put myself through the exercise of parallel coding (as I recommended in previous posts), I found I didn't need Einstein's IQ to translate between ICD-9 and 10 codes. The ICD-9 codebook lists codes numerically and alphabetically. And guess what? So does the ICD-10 book.
More importantly, the ICD-10 codes were more precise and descriptive. As I mention in Part 3, in many cases I was able to find one ICD-10 code when the same diagnosis required at least two ICD-9 codes. For example, ICD-10 includes specific codes for puncture wounds, bites and abrasions that ICD-9 does not.
Would there have been production issues during the ICD-10 ramp up? Of course. Every country that implemented ICD-10 experienced this. But with all the preparation and practice already undertaken by industry stakeholders and the more intuitive nature of ICD-10, these issues would be manageable — and would ultimately lead to a much better system for all.
There are too many codes. There is no arguing that ICD-10's 70,000 diagnosis codes outnumber ICD-9's 18,000. And I will admit that scare tactics about the number of codes were used by my industry to sell training and consulting. So messages about "physician burden" weren't coming from the AMA alone.
But there are several reasons that the numerical differences between ICD-9 and 10 can be misleading:
- 90/10 rule. Most practices use only a small proportion of diagnostic codes. And even practices like emergency medicine that treat a wide variety conditions have a relatively small universe of common diagnoses (finger laceration, ankle sprain, abdominal pain, etc.).
- Massive revisions to superbills. This is a reasonable concern for small-to-medium-size practices. It would have taken some creative formatting and maybe additional ink to come up with comparable ICD-10 superbills. But then again, aren't paper superbills going the way of 8-tracks? After all, we are mandated to move toward an electronic system. We also have a robust coding industry both stateside and abroad. Hopefully it will soon be possible for all providers to electronically outsource their coding needs.
- Statistics can be misleading. ICD-9 may have fewer codes, but it also relies on a 3–5-digit decimal system to achieve desired specificity. Instead of decimal points, ICD-10 has a code for most diagnostic scenarios.
ICD-10 is hopelessly complex. The ICD-10 proficiency exams offered by AAPC and AHIMA have very high pass rates (over 80 percent ). That's actually higher than the pass rates for initial coding certification exams. And sure, S916.919A (ICD-10) looks like algebra compared to 845.00 (its ICD-9 counterpart). But S96.919A is for "ankle sprain, initial encounter." By contrast, ICD-9 does not differentiate between sprain and strain. And the new "initial encounter" designation provides valuable information to other clinicians about the history of treatment.
A powerful example is the ICD-9 code 729.5, "extremity pain." It looks simple, but the same code is used to indicate everything from pain in the toe (729.5) to pain in the upper arm, (729.5). On the other hand, ICD-10 actually has separate codes for toe pain, (M79.974, "pain in right toe") and arm pain (M79.62, "pain in right upper arm"). Sure there are more codes in ICD-10. But doesn't the medical community want to communicate exactly where pain is located through its coding system?
And those strange codes with X's? They're simply markers to allow for future expansion as additional medical knowledge and information comes available. As healthcare systems sales people would put it, ICD-10 is scalable!
A delay of ICD-10 may have been appropriate for a number of reasons, including insufficient time for end-to-end testing by CMS. And my industry is encouraging its members to use the delay for further training and testing.
However two major obstacles to ICD-10 implementation remain.
First, the delay is legislative and in response to intense lobbying efforts. Congress has effectively taken control of ICD-10 implementation from HHS/CMS. Regulators have been silent and will probably remain so in deference to Congress.
Second, the delay is open-ended, opening the door for future delays.
I have recommended public advocacy for ICD-10 to my industry organizations and encourage AMA and ACEP to join us for all of the reasons I have outlined. ICD-10 is simply better for your patients.
For those stakeholders who have bought into ICD-10, I ask you to advocate for the system in your societies and in conversation with your colleagues and hospital contacts. Without advocacy from all segments of the Acute Care Continuum, we might be looking at 17 more years of delays.