Healthcare // Clinical Information Systems
Commentary
4/16/2014
09:16 AM
Mark Braunstein
Mark Braunstein
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ICD-10 Delay: Politics Trump Health Data Quality

With a fresh delay for ICD-10 compliance, US healthcare providers and patients remain trapped in debate. Is higher quality clinical data worth the cost of more detailed data collection?

Easy-to-Mock ICD-10 Diagnosis Codes
Easy-to-Mock ICD-10 Diagnosis Codes
(Click image for larger view and slideshow.)

Progress toward more specific medical data gathering has been halted, once again.

President Obama recently signed the "doc fix" legislation (HR 4302) to delay scheduled cuts to Medicare physician reimbursement rates. The bill also pushes back the ICD-10 compliance date until at least October 2015, further delaying the switch from ICD-9 to ICD-10, which was endorsed by the Forty-third World Health Assembly in May 1990 and released to WHO member states 20 years ago in 1994.

The switch to ICD-10 means that health care providers and insurers will have to replace 14,000 codes with 69,000 codes. These two numbers are often cited by opponents as an undue burden on already busy hospitals and physicians. Terry Gunn, CEO of KershawHealth in South Carolina, said the delay would give hospitals more time to get ready for the "huge, overwhelming task" of ICD-10 implementation. A senior policy adviser to the Medical Group Management Association said that it is "recognition that the industry is simply not ready for the transition."

[Want more on the ramifications of delaying ICD-10? Read ICD-10: Painful To Implement, Painful To Delay.]

On the other side, CMS estimates that a one-year delay could cost between $1 billion and $6.6 billion, according to a blog post by the American Health Information Management Association (AHIMA), which opposes the delay. AHIMA also says that the delay affects some 25,000 of its students who have learned to code only in ICD-10, and that it affects "much more than just coded medical bills, but also quality, population health, and other programs that expected to start using ICD-10 codes in October." CHIME's president criticized Congress, saying, "Further delay of ICD-10 discredits the considerable investment made by stakeholders across the country to modernize health care delivery."

So, where is the truth and what does all of this mean?

With health informatics under pressure to help re-engineer our sick healthcare delivery system, ICD-9 has significant shortcomings. To give but one commonly cited example, ICD-9 does not code for laterality. To see an example of this problem, I suggest you go to the free, public ICD-9 code lookup on the CMS website. Type in "breast malignant neoplasm" and you'll find 15 results that do suggest where in the patient's affected breast the cancer is located but do not tell you which breast is affected. Try the same thing with an ICD-10 lookup, and you'll get 30 results that clearly separate the disease by the affected side.

This isn't the only difference, just an easy example. ICD-10 offers significantly more clinical specificity than its predecessors. Here's an illustration of that from my new text book Contemporary Health Informatics:

ICD-10 codes with progressive levels of detail.
ICD-10 codes with progressive levels of detail.

For another example, search on the CMS site for "chronic gout." This search returns two codes indicating whether a tophus -- a deposit of urate crystals that forms over time with poorly controlled chronic gout -- is present. But unlike the ICD-10 code, the ICD-9 code tells us nothing about where it is.

It is not hard to imagine how this added specificity could benefit those interested in the secondary use of health data for research, public health, and other analytic purposes, but where do increases in Medicare costs come from? Estimates of fraud in healthcare vary from 3% to up to 10% of all costs. The Institute of Medicine put that number at $75 billion annually over a decade ago. Among the most common forms of fraud is duplicate billing, charging twice for the same thing. More clinical detail is an obvious benefit for efficiently and systematically investigating this. A gout patient can have more than one tophus, and they can be removed surgically when indicated. Is the removal being done today the same tophus that was removed last year? It's hard to tell if there is no data on where the two tophi were located.

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Mark Braunstein is a professor in the College of Computing at Georgia Institute of Technology, where he teaches a graduate seminar and the first MOOC devoted to health informatics. He is the author of Contemporary Health Informatics (AHIMA Press, 2014) as well as Health ... View Full Bio

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Mark Braunstein
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Mark Braunstein,
User Rank: Moderator
4/18/2014 | 10:50:17 AM
Re: ICD-10 different in the U.S.
Well, in theory, that's what the ICD codes are for.  In practice because claims data is so widely available and so consistent as compared to clinical data from EHRs, it is used for many secondary purposes beyond billing.  Moreover, this added detail is potentially important to payers for purposes such as spotting fraud (e.g. second amputation of the same finger).
5Tool
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5Tool,
User Rank: Strategist
4/16/2014 | 9:01:08 PM
Re: ICD-10 different in the U.S.
ICD-9 id just a diagnosis tool for insurance purposes. What do you care if the cancer is in the left or right knee? It is the same amount of money to fix it, right?
Mark Braunstein
IW Pick
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Mark Braunstein,
User Rank: Moderator
4/16/2014 | 10:57:14 AM
Re: ICD-10 different in the U.S.
I don't want to appear insensitive to the work involved but you only learn how to swim by diving in.  We need to get on with this or decide we're never going to do it (a big mistake, I think).  Some parts of the markets (providers and HIT vendors) may never take it seriously enough until its for real.  If we wait for everyone to be ready it will never happen!
David F. Carr
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David F. Carr,
User Rank: Author
4/16/2014 | 10:35:23 AM
Re: ICD-10 different in the U.S.
I think the skeptics were under-confident that they would have a "well-designed HIT tool" at their disposal as of October 1.
Mark Braunstein
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Mark Braunstein,
User Rank: Moderator
4/16/2014 | 10:03:47 AM
Re: ICD-10 different in the U.S.
I can't resist pointing out that nothing is ever "simple" in the US because our healthcare system is so overly (and I think needlessly) complex.  Having said that, here's the CMS counter argument from their ICD-10-CM/PCS Myths and Facts document I would recommend to anyone wanting more details.

"Just as an increase in the number of words in a dictionary doesn't make it more difficult to use, the greater number of codes in ICD-10-CM/PCS doesn't necessarily make it more complex to use. In fact, the greater number of codes in ICD-10-CM/PCS make it easier to find the right code. In addition, just as it isn't necessary to search the entire list of ICD-9-CM codes for the proper code, it is also not necessary to conduct searches of the entire list of ICD-10-CM/PCS codes. The Alphabetic Index and electronic coding tools will continue to facilitate proper code selection. It is anticipated that the improved structure and specificity of ICD-10-CM/PCS will facilitate the development of increasingly sophisticated electronic coding tools that will assist in faster code selection. Because ICD-10-CM/PCS is much more specific, is more clinically accurate, and uses a more logical structure, it is much easier to use than ICD-9-CM. Most physician practices use a relatively small number of diagnosis codes that are generally related to a specific type of specialty."

I'm not sure I entirely buy this but a well designed HIT tool should pretty much accomplish what CMS envisions here.


BTW, after I submitted the post a new survey came out showing that nearly 60% of health care providers are disapointed in the further delay. It sounds like the providers are tired of the drill and want to get it over with and move on.
David F. Carr
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David F. Carr,
User Rank: Author
4/16/2014 | 9:41:01 AM
ICD-10 different in the U.S.
Mark, How do you respond to the argument that the version of ICD-10 proposed for use in the U.S. is different (and much expanded) from what's been used in the rest of the world? Many of the ICD-10 skeptics I've talked with argue the U.S. added a lot of additional complexity to make the diagnosis codes work for insurance billing as well as statistical tracking.
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