ICD-10: Painful To Implement, Painful To Delay

If the implementation of ICD-10 diagnosis codes is delayed by an act of Congress, as seems likely, doctors may be spared a headache -- but healthcare CIOs will gain one.

Easy-to-Mock ICD-10 Diagnosis Codes

The Centers for Medicare and Medicaid had set forth a firm October 1 deadline for the implementation of a new and vastly expanded system of diagnosis and insurance billing codes, a transition that has been in the works since the 1990s and had been pushed back repeatedly. On Thursday, the US House of Representatives passed a "doc fix" bill including a one-year extension of the deadline. The ICD-10 provision is one paragraph in a larger bill mostly focused on postponing cuts in Medicare reimbursement to doctors that would otherwise be required under the Sustainable Growth Rate formula, which was part of a cost containment act passed in 1997. The ICD-10 provision seems to have been thrown in as a consolation prize for the physician's lobby, after efforts to permanently repeal the SGR formula fizzled, and this latest compromise won the backing of both Speaker of the House John Boehner and Senate Majority Leader Harry Reid. The Senate is scheduled to vote Monday night. [Update: the bill passed the Senate 64-35.]

[ What's the next step with healthcare analytics? Read Growing Beyond Yesterday's Population Health Management.]

The American Medical Association decried this compromise, but not out of any love for ICD-10, which the organization predicts will be extremely costly for physicians, meaning that "the AMA continues to work to stop its implementation altogether."

The AMA estimates the cost of switching to ICD-10 at as much as $8 million for a large physician practice and more than $225,000 for a smaller one. AMA's objection to the doc fix bill is that another temporary delay to SGR is not good enough. "There was bipartisan, bicameral support for reform this year, yet too many in Congress lacked the courage and wherewithal to permanently fix Medicare to improve care for patients and provide greater certainty for physician practices. Congressional leadership had to resort to trickery to pass an SGR patch that was opposed by physicians," according to a statement from AMA President Ardis Dee Hoven, MD.

As a practical matter, doctors are still likely to prefer a delay to both SGR and ICD-10 implementation to no relief at all. Doctors worry that, with about 64,000 very specific ICD-10 codes, they will have a much harder time recording the right data to get their claims paid by CMS and by insurers.

"There's going to be complete confusion if you don't do everything right in the billing process and fill it out the right way," one emergency medicine doctor told me. "This is another way of not paying you -- that's the cynical view." I'm withholding his name because the quotes he gave me on the record were much so less colorful. If a doctor records the diagnosis code of "congestive heart failure" rather than one of the 29 more specific codes for types of congestive heart failure included in ICD-10, "then they just don't reimburse you for the visit or the care of the patient," he said. "People could wind up going bankrupt in medicine, because they're not getting reimbursed for anything because it's so complex."

As an emergency department specialist who works at several different hospitals, he also can't count on the EHR systems to save him by simplifying the process of looking up codes. Because the hospitals all use different EHRs, he expects that he really is going to have to memorize at least the most common ICD-10 codes if he wants them to be captured properly for his bill (which is separate from the hospital's bill). This is one case where the priorities of the institution are different from those of the physicians.

Rob Tennant, senior policy adviser for the Medical Group Management Association, said the government still hasn't invested in enough testing and preparation for the transition to ICD-10 and it shouldn't be rushed. "The proponents tend to be people who aren't responsible for the financial costs of this transition." Doctors in private practice and group practices are the ones most likely to "pay out of pocket," he said.

Also, with the rocky launch of HealthCare.gov still a recent memory, lawmakers are sympathetic to worries about the implementation of another big government-led technology project, Tennant said.

Meanwhile, hospitals and the healthcare IT community are decrying the cost of delay. The legislative initiative is "a real disappointment to CHIME members, who have long prepared for ICD-10, installing new systems, training staff and otherwise making the needed changes that will affect patient care," Russell P. Branzell, President and CEO of the College of Healthcare Information Executives (CHIME) said in a written statement.

CHIME also participated in a joint statement of opposition from the Coalition for ICD-10, which is made up mostly of technology-oriented groups, including the American Medical Informatics Association and the American Health Information Management Association, which represents coders and other professionals who collect and analyze healthcare information. The coalition also includes the American Hospital Association, the BlueCross BlueShield Association, and WellPoint.

Dan Haley, Athenahealth's vice president of government affairs, said it's true many doctors are anxious about the change but that's because their technology vendors have let them down, whereas "we did the work to get our doctors ready." For the government to insist that the industry and its technology vendors meet a given standard, and then back off, is a bit like parents telling their children "no dessert unless you eat your dinner -- and then you don't eat your dinner, but you still get dessert."

Many healthcare IT organizations took it for granted that the government would punt the deadline yet again, and it looks like they were right, Haley said. "Anecdotally, what we've heard is that the doctors groups, in exachange for not making too much noise about SGR, will get the ICD-10 delay. I'd say there's a 90 percent or better chance this whole thing passes. It's pretty rare you have bipartisan leadership in both chambers ramming something through."

American Health Information Management Association CEO Lynne Thomas Gordon acknowledged the political odds seemed to be stacked in favor of the bill's passage. "I'm holding out all hope. It would be such a shame" if the delay passes, she said, after all the work her members have done to gear up for the change.

The current coding scheme is "ancient, with no more room to upgrade codes" and fails to include categories for modern worries like bioterrorism or even to distinguish between a wound on the right side or the left side of the body, Gordon said. In the absence of precise codes, coders wind up fudging their records with approximate descriptions based on the code that is the closest match, she said. "We feel very strongly that ICD-10 is more granular, more specific."

A delay would also be harmful to more than 25,000 students currently studying to work as medical coders -- many of whom have been trained exclusively on ICD-10 under the understanding that it would be the exclusive standard by the time they graduated, Gordon said.

Cleveland Clinic CIO Martin Harris, an MD who has spent his career seeking better ways of analyzing health data, said the greater specificity in ICD-10 will translate into better tracking of how care is delivered and how it can be improved. "Used properly, there is no question we'd get a refinement around what we know about caring for patients clinically." On the other hand, he added, "To get to those refinements, there's a cost -- someone has to enter the data this way." His IT organization is trying to minimize the potential loss of physician productivity by designing EHR screens that make it easy to pick the most frequently used and appropriate codes, but exactly how that nets out remains to be seen.

Whatever the tradeoffs, delaying ICD-10 now will have its own negative consequences, Harris said. "It would be an enormous impact on the training programs we have set to take place over the next six months," for which teams of trainers and facilitators have already been assembled. "If we were to say 'stop' now, those teams have to go away, and then they would be reassembled," gearing up to do the same thing again next year. "That's where you'd see the expense. Starts and stops are never good for the budget."

With the legislation including the delay seemingly likely to pass, Harris said his staff "is scrambling right now," trying to figure out the best way to salvage the work in which it has invested. He is holding out some hope that it might be possible to negotiate some way that "those organizations that are ready to go could continue to move forward" and start submitting data in ICD-10 format, even if it would not be mandatory for those who are unprepared for the transition. Whether that's something payers would agree to he wasn't sure.

In a separate interview, AHIMA's Gordon suggested that was a nice thought, but probably impractical. "I would think that would be very difficult for the industry. All of your payers would have to support dual coding systems, which would be very onerous."

One way or another, it seems, someone is going to feel the pain.

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