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ICD-10 under Fire

November 23, 2011
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Is ICD-10 too much of a burden?

The American Medical Association at the close of its semi-annual policy meeting this month voted to “work vigorously to stop implementation of ICD-10,” the classification system of 69,000 codes that will replace the 14,000 codes currently in use under ICD-9. Peter W. Carmel, M.D., AMA president, in a statement, is that the new code set would place an added burden on physicians. “The implementation of ICD-10 will create significant burdens on the practice of medicine with no benefit to patient care.”

He added: “At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records into their practices. We will continue working to help physicians keep their focus where it should be—on their patients.”

The statement also cited a 2008 study that found that a three-physician practice would need to spend $83,290 to implement ICD-10, and a 10-physician practice would spend $285,195 to make the coding change.

The next day, the American Health Information Management Association published a response countering the AMA’s position. AHIMA CEO Lynne Thomas Gordon said, “We need to move our classification system toward international standards and also align it with the Meaningful Use incentive program as well as value-based reimbursement. The provider reimbursement system is moving to payment for quality care and the use of a more contemporary, detailed coding system that will support quality care, public health, and research both nationally and internationally.”

AHIMA Director of Coding Policy and Compliance Sue Bowman noted that the U.S. classification system has essentially run out of codes and cannot fully express 21st Century medical knowledge. “The move to electronic health information and exchange will not benefit the public if we do not also improve the information that these new systems will create and exchange.”

AHIMA also noted that a slowdown in implementation would result in delays to implementations of electronic health records and health information exchanges, and have a negative impact on quality-based reimbursement.

A few months before this exchange, John Halamka, M.D., presented a thoughtful analysis on ICD-10 implementation in his blog, Life as a Healthcare CIO. On September 21, he characterized the transition as a “Y2K for healthcare.” He notes that the Centers for Medicare and Medicaid Services and the Department of Health and Human Services have significant reasons for moving ahead, including easier fraud detection, more detailed quality reporting, and the ability to make more refined reimbursements.

He added that large healthcare organizations have already invested on the transition, and delays would only cost them more. On the other hand, small and medium provider organizations are already stretch with meeting meaningful use and other mandates, and lack the resources for a large ICD-10 transition project. Halamka notesd that the government estimates that benefits will far outweigh costs, but he suspects that the cost estimates are on the low side.

Halamka also maintained that ICD-10 perpetuates a reimbursement system that is already too complex. In his view, the added granularity of ICD-10 is laudable for its research value, but is not affordable. He also adds that while ICD-10 is used in other countries, it is for health statistics and reporting, not for reimbursement purposes. He says that a fresh look at reimbursement is needed.

All of which are valid points. But I find it hard to argue for more delays. As noted in the AHIMA response, HHS authorized the U.S. to adopt ICD-10 in early 2009, and a U.S. version of ICD-10 has existed since the late 1990s. Also, ICD-10 is part of a multi-faceted healthcare reform effort that has gained momentum. Given that, I think now is the time to push forward, not hold back.



John, I believe that a sometimes overlooked beneficial outcome of the transition to ICD-10 will be improved EMR physician documentation and a standardized physician problem list. Medical coding will require improved clinical documentation to assign the correct, more precise ICD-10 code. Improved clinical documentation will enhance the value of the EMR, and will eventually lead to wider adoption of interoperable health records. I recently attended a Virginia HIMSS meeting, and many participates indicated they were well down the road in their transition to ICD-10.

Thanks for pulling together this updated review of the ICD-10 public discussion. I agree with you and Chip Perkins. Here's why.

The AMA argument that the transitions will lead to "no benefit to patient care" falls flat. It's hard to point to significant improvements in healthcare costs, quality and access in recent decades, despite the introduction of powerful and effective technologies, as well as strong demonstration projects showing paths to improving all three (care cost, quality and access.)  As identified by many, payment reform is essential.

As recently demonstrated in a standards tutorial by Dr Chris Chute at AMIA, the ICD evolution from nine, along with the concurrent and related SNOMED evolution provide a strong basis to support requisite improvements in providing specific clinical terms. Without these, needed improvements, including those cited by Halamka are illusive management goals (ie cost, reimbursement, quality improvements) because of poor and inadequate underlying measurement. The proceedings of the HITPC and HITSC clearly focus on pragmatic, measurable process steps to these outcomes. Promoting ICD-9 inertia does not support those improvements.