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Article by Mary Butler, associate editor at the Journal of AHIMA. This article was originally published on the Journal of AHIMA website on February 11, 2015, and is republished here with permission.
Healthcare professionals that work with coded data on a daily basis were well represented in the US House of Representatives’ Energy and Commerce Subcommittee on Health hearing, titled “Examining ICD-10 Implementation,” which took place Wednesday morning in Washington, DC. With panelists representing those both for and against an outright switch to the new ICD-10 code set on October 1, 2015, the subcommittee representatives listened to debate on stakeholder ICD-10 readiness, implementation costs, and the impact another delay would have on the healthcare industry.
Panelist Sue Bowman, MJ, RHIA, CCS, FAHIMA, AHIMA’s senior director of coding policy and compliance, urged Congress in her testimony not to enact further delays and allow the US to keep pace with other industrialized nations who adopted ICD-10 years ago.
“So the industry initially had more than four years after publication of the final rule to prepare for the ICD-10 transition. As a result of the two one-year delays granted by HHS [Department of Health and Human Services] in 2012 and Congress in 2014, the healthcare industry has had more than six years to prepare,” Bowman said. “This length of time is more than adequate for all segments of the healthcare industry to be ready for the transition.”
Panelist Dr. William Jefferson Terry, MD, representing the American Urological Association, as well as his own practice, voiced concerns about lost physician productivity if ICD-10 is adopted too quickly.
“Physicians are overwhelmed with the tsunami of regulations that have significantly increased the volume of work for physicians and their staff, many of which have questionable value to improving the quality of care provided to patients,” Dr. Terry stated during the hearing. “Many physician practices, especially the rural one- or two-physician practices do not have the time, money, or expertise to follow and comply with the mounting regulatory challenges, which is why many are considering early retirement or opting out of the Medicare program.”
Proponents of implementing ICD-10-CM/PCS on the October 1, 2015 deadline likely left the hearing with optimism, based on the testimony of the panelists and comments from key committee members.
At the outset of the hearing, Rep. Joe Pitts (R-PA), the subcommittee’s chairman, voiced his support for moving forward with ICD-10 implementation in October 2015. This was particularly notable since Pitts inserted the language into last year’s “Protecting Access to Medicare” bill that delayed ICD-10 implementation by an additional year.
Rep. Kathy Castor (D-FL) also spoke out in support of an October 2015 implementation, and Rep. Tony Cardenas (D-CA) noted the California Hospital Association’s advocacy efforts to keep implementation on track for this year.
Of the seven industry experts who testified today, only one—Dr. Terry, from the Mobile Urology Group—outright opposed implementation in 2015. ICD-10 advocate panelists at the hearing included Edwin M. Burke, MD, from the Beyer Medical Group; Richard Averill, from 3M Health Information Systems; Kristi A. Matus, from insurer Athena Health; Carmella Bocchino, from America’s Health Insurance Plans (AHIP); and John Hughes, MD, a health data researcher and professor of medicine at Yale University.
Hearing Dispels Persistent Myths
The hearing allowed panelists and committee members to enter into evidence a series of recent reports, surveys, and government studies looking at concerns such as the cost of implementing ICD-10, particularly for small and rural physician practices, the cost of delaying the code set any further, and the impact on the quality of care of implementing a more granular code set.
Panelists and committee members cited the recent GAO report on the Centers for Medicare and Medicaid Services (CMS) ICD-10 readiness, which overall stated CMS was supporting providers in the transition and was ready for the October implementation date, as well as new white papers stating lower-than-expected industry costs for ICD-10 implementation.
Ranking member of the committee Rep. Joe Pallone (D-NJ) asked Bowman directly to address how ICD-10 can help detect fraud, how it impacts new payment reforms, and why the healthcare system needs stronger data. Pallone also asked Bowman how ICD-10 makes reimbursement more fair and accurate.
“With ICD-9 deteriorating, we’re getting less and less information from [patient and physician] encounters. We’re getting less information about what’s being treated. So many disparate procedures are lumped into a single code,” Bowman said.
For example, Bowman explained that the procedure codes for suturing an artery in ICD-9 doesn’t specify whether the artery being repaired is an aorta, or a much smaller artery for something like a finger laceration.
“There are enormous differences in complications and cost of repairing the artery. On the procedure side, we can fine tune information about the cost of treatment, which links to reimbursement,” Bowman said.
Pallone also expressed concerns by others on the panel that ICD-10 was created by bureaucrats, without input from the medical community.
“That’s been the biggest myth, that it was developed in a closet,” Bowman said. “I’ve been involved in the development of ICD-10 since the 1990s. All of the content of the original ICD-10 that the World Health Organization (WHO) uses, all of it is contributed to greatly by the House of Medicine, which participated in development and asked for this detail.”
ICD-10 implementation opponent panelist Dr. Terry and some committee members—including Rep. Larry Buschon, MD (R-IN)—expressed concern that ICD-10 does not improve the delivery of care while a physician is in the middle of a patient visit, and therefore shouldn’t be a priority.
“I don’t treat patients based on a code,” Dr. Terry said. In addition to representing the American Urological Association (AUA), Terry also works for an Alabama urological practice.
In response, Bowman noted that some clinical practices are using ICD-10 codes to improve disease management for conditions such as diabetes and asthma. Hughes, the Yale researcher panelist, said that more specific data can help him and fellow investigators track treatment trends for diseases and improve surveillance efforts for medical complications.
3M’s Averill also responded to Terry’s assertions.
“Much of this specificity [in ICD-10 procedure and diagnosis codes] has been requested by the medical community. The AUA has asked for 250 new codes. Urologists have been asking for additional codes. What is interesting about this is we are getting pressure from the medical community for more precise information and more codes while hearing a reluctance to invest in it,” Averill stated.
Concerns Remain Regarding ICD-10-Related Costs
A number of medical professionals in Congress are on the committee that held today’s hearing, including Rep. Buschon, who has specialized in cardiothoracic surgery, and Rep. Renee Ellmers (R-NC).
“I am a nurse, my husband is a surgeon,” Ellmers said. “I believe that frustration exists. I want to see ICD-10 move forward in the real world, rather than theoretical world. One of the big issues is the cost. Our hospitals have invested millions. Is there a cost incentive?”
Averill pointed to a new white paper showing that, according to a recent survey, ICD-10-related expenditures for a physician practice with six or fewer providers is $8,167 with average expenditures per provider of $3,430. This estimate is much lower than previous reports, which occurred, Averill said, before significant government, vendor, and provider support was developed for ICD-10 implementation.
Panelist Edwin M. Burke, MD, who works for a two-physician practice in a Missouri town with a population of 4,000 people, testified that the transition to ICD-10 in his practice cost next to nothing because his vendor automated the process.
Terry, who works in a urological practice in Alabama, took issue with the notion that transition costs can be so low. “If you don’t have a contract, you’re stuck. I have to do what the company tells me to do. I can’t bargain costs,” Terry said.
Averill maintained that the market has responded with multiple free and low-cost software and training materials. Additionally, the multiple delays to ICD-10 implementation has allowed more resources to proliferate and help providers with the transition.
Among other committee members, Rep. Michael Burgess, MD (R-TX), wondered why providers, insurers, and CMS must choose between ICD-9 and ICD-10, asking if allowing both coding systems during the transition would help.
AHIP’s Carmella Bocchino noted that using both coding systems, or dual coding, is cost prohibitive for payers and providers beyond short-term test runs.
“Running dual systems is just not feasible—it’s very costly. What plans are doing on Oct. 1, they’re switching to new algorithms and new codes, two tracks will be too confusing,” she said.
Athenahealth’s Kristi Matus, while an advocate for keeping ICD-10 on schedule for October, said the uncertainty circling another delay has hard and soft costs, and urged committee members to “Pull the trigger or pull the plug.”
But she also made a case for why ICD-10 is critical in improving the US healthcare system.
“ICD-10 is not a silver-bullet. But on the spectrum of needed systemic changes, it is a comparatively simple one—the technological equivalent of an upgrade from a relatively simple dictionary to a more complex one,” Matus said.