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ICD-10 Buzz Was Humming At HIMSS

February 27, 2012
by Joe Bormel
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ICD-10 delay was greeted by different people with wildly different reactions

During the past 18 months or so, I have talked with many hospital CIOs and HIM professionals. I’ve been impressed with how so many organizations have accepted the transition to ICD-10, and have had plans to do so in place for some time.


My impression is that hospitals are moving right along toward meeting the transition’s October 2013 deadline. And according to the surveys I’ve read, most feel they will make it. But now, CMS may move that deadline out, which has the potential to severely complicate training and implementation cycles. There was a lot of buzz about a delay at HIMSS last week, and that is the topic of my blog.


This year, HIMSS occurred almost concurrently with the comment by CMS acting administrator Marilyn Tavenner indicating the implementation of ICD-10 may be delayed. The announcement of an ICD-10 delay was greeted by different people with wildly different reactions. Here are a few of their comments:


1. “Thank goodness,” said a CFO. This was the refrain of almost everyone currently in the active roll-out process of some other healthcare IT initiative that is massive. Many have done some preliminary assessment and project planning for ICD-10, but knew they were only 5 percent into a massive training, building, analysis and roll-out by the current October 2013 deadline.


2. “A delay will seriously damage my credibility within my organization, from the C-suite on down.” This was the lament of many CIOs who had done their homework, developed solid plans through a painstaking process, and most importantly, educated their executives that the current deadline was firm. All indicators suggested the government would stand firm on the 2013 date. Now we learn CMS is uncertain about its commitment.


3. “This was inevitable and the sober thing to do,” a physician told me. The thinking here goes along the lines that it's too great of a burden on the doctors and the improvement in data quality is of negligible consequence to patients or doctors. The true intent of those promoting the transition is to further reduce reimbursement to providers for care. Note this is contrary to the position AHIMA has steadfastly professed for many years.


4. “Moving the date introduces significant new logistical challenges.” That came from a hospital HIM director. When there was a specific switch over date, the logistics of getting ready and meeting a fixed deadline were clear and manageable. It's been done in other countries, in fact, most other countries – long ago. If we move the date to a window of time during which dual systems are allowable, we will have to use systems that weren't designed for dual use. This will introduce new workflow requirements and complicate enforcement.


I expected reaction number one. The other three I understand, but speak to issues that won’t be fixed by simply moving the date.


Is the fact that SNOMED is the only code set now allowed for problem lists in the Notice for Proposed Rulemaking for MU Stage 2 a precursor for delaying the deployment of ICD-10? Does a delay indicate that CMS places more importance on the lobbying by groups whose members have, for a number of reasons, not implemented a plan for the transition to ICD-10, as compared to the tens, perhaps hundreds of millions of dollars invested by vendors and healthcare providers determined to meet the existing deadline?


Healthcare providers face multiple deadlines to implement new systems and methodologies designed to improve quality of care, patient safety, and streamline reimbursement. The deadlines for implementing EDI 5010 and MU Stage 1 have already been pushed out. Is it proper to do the same for ICD-10, knowing that in 2009 the deadline was changed from 2011 to 2013, and considering the development of ICD-10 was completed in 1992, with about 110 other nations already using the system?


What do you think?


Joe Bormel

CMO and Vice President

QuadraMed Corporation





Dr. Bormel,
Your post is excellent. The questions you have raised are not only valid, they are needed. I applaud your willingness to raise them. Many other physicians would not.

I’m dismayed by the position the AMA has taken, especially as a member of the organization. But then, AMA opposed adoption of CPOE roughly a decade ago as unnecessary and too costly. Just another blunder that ultimately defied common sense.

Our hospital is well into seven figures, not budgeted but spent, on the transition to ICD-10. Our plan is working very well and we will meet the existing deadline, because we began formulating it in a timely and prudent manner.

As you pointed out, healthcare providers received a two-year reprieve from the original 2011 deadline in 2009. Unfortunately, that extension may have motivated those opposed to ICD-10 to fight on in an attempt to permanently stall its implementation. I find this disgraceful and without merit.

The benefits of ICD-10 are proven, and those benefits include a reduced risk to challenges for proper reimbursement. In a time of extended economic crisis, changing the 2013 deadline is not only poor medicine, it’s poor business.

Many of the physician group practices I am personally aware of, those providers AMA infers are so negatively impacted by ICD-10, subcontract their coding and billing to outside vendors. That translates to the docs needing to do some homework on how to properly report the treatment and services they provide. Best practice, in part, means we never stop learning. So those who protest against ICD-10 need to get on board and stop complaining. They have had more than four years to transition, and yet maintain a stance of “poor, poor pitiful me.” In short, a pitiful argument.

Many nations, with far fewer resources at every level than ours, have deployed ICD-10. As you noted, the development of this coding system was completed in 1992. There is absolutely no excuse for the United States to be 20 years behind the times. I am a physician with over 35 year’s experience. Yes, an old guy. But over the years, I’ve learned the value of change, particularly in healthcare IT. I commend the ongoing efforts by professional associations such as AHIMA. They have a true and global understanding of the situation.

Our hospital will experience a major, costly, and negative impact should the deployment of ICD-10 be delayed. I find this unacceptable, as do my immediate peers.

We have all, I think, become somewhat calloused to the “big money” lobbying in Washington that continues to skew our national agenda in almost every area. That said, should we not expect more from our profession and industry? I, for not just one, ask if you have any suggestions. This question is not meant to back you in a corner, nor meant to ask you for a politically oriented statement.

You are an industry leader. That is obvious because, in no small part, of your continued presence on this website. So do you have any observations about how we can deal with this situation and get through the challenges with a minimum of negative impact?

Doc Benjamin

Doc Benjamin,

Thanks for your comment. Here are my thoughts on your questions:

  • We don’t know the nature of the CMS delay at this point. For many organizations, it's going to make sense to continue to push forward with their ICD-10 plans, with selective dual coding, especially in sensitive areas.
  • On the physician front, the clinical documentation improvement initiatives can improve data quality in both ICD-9 and ICD-10.
  • I would recommend that readers go back to my earlier posts on problem lists. The work of MU in terms of problem lists, CPOE, and reporting, especially given what we now know about the Stage 2 NPRM makes developing a SNOMED-based care delivery competency a must.
  • Probably half of my clients have an active accountable care ambition, which demands rigor around care hand-offs within their communities. The work will provide a natural basis to incorporate ICD-10, no matter what delays may occur.
  • Regarding the political and economic distinctive features of the U.S. system, I think that comparisons with other OECD nations breaks down very quickly. I agree with observations that we need to improve safety, timeliness, effectiveness, equity, patient-centeredness and efficiencies of care; there's lots of room for improvement. Although ICD-10 is clearly a significant improvement over ICD-9, the needed modernization of the coding system is a relatively small part of the health system overhaul that is underway.
  • Thanks again for your comments.

    At HIMSS, I talked to people of all 4 persuasions. One, a major health insurer, said they'd already invested $100 million getting ready for ICD-10, only to 'have the rug pulled out from under them.' Figure 20x that $ figure for all payers other than Medicare/Medicaid and 3x that for all providers (a really rough swag), and the capital investment in ICD-10 looks like about $8 billion, plus Medicare and Medicaid. HHS has been proposing ICD-10 cutover dates beginning with years back as far as 1994. Final rules for the 2013 cutover date were published in 2009. Two decades of planning.

    $8 billion is a lot of capital to raise for health care administrative systems. If ICD-10 is implemented as a HIPAA-mandated medical code set, then maybe a good part of that investment will not be lost.

    More serious is the meta-message from Washington: decisions are ultimately made by politicians, and if you believe their promises, you do so at your own peril.

    Thanks for your comments. Your closing point on "belief in promises" reminded me of this poem by Veronica A. Shoffstall:

    “After awhile you learn the subtle difference
    between holding a hand and chaining a soul.
    And you learn that love doesn't mean security,
    And you begin to learn that kisses aren't contracts
    And presents aren't promises.

    And you begin to accept your defeats with you head up and your eyes open.
    With the grace of maturity, not the grief of a child.
    And you learn to build all your roads on
    Today because tomorrow's ground is too uncertain for plans,
    And futures have a way of falling down in mid-flight.

    After awhile you learn that even sunshine burns if you get too much.
    So you plant your own garden and decorate your own soul,
    Instead of waiting for someone to bring you flowers.
    And you learn that you really can endure...

    That you really are strong
    And that you really do have worth.
    And you learn and learn and learn ....
    With every goodbye you learn.”

    - copied from http://thinkexist.com/quotes/veronica_a._shoffstall/

    Well over a year of discussion of the trifecta of MU, ICD10 and PPACA (ObamaCare) being too much to put on hospitals and docs and NOW CMS decides to look at the regulatory burden.

    That is like if I asked my husband to paint a room. By the time he gets out all the supplies, lays the dropcloth and gets rolling--I come back and tell him to wait. That I am not quite sure and am going to think about it some more.

    He would be furious with me--just like I am with CMS...

    Interesting analogy.

    When I was in medical school, the family practice society offered extracurricular lunch time training for interested students. One session was on how physicians should provide premarital counseling. It touches on your example.

    The two take-home lessons were, one, "Men and Women are fundamentally incompatible; we're not saying dont get married; we're saying, have reasonable expectations."

    The second lesson was "The key to a successful marriage is fighting fair. That means, among other things, dont bring arguments from old fights into new ones."

    From a sense of Fairness, you would be right to be furious. As per the "After a While" poetic comment in this post, Fairness isn't the standard. That said, most of us are still married or at least tied to CMS in one way or another. And we both know that marital counseling is not an option. :)

    Thanks Dr. Joe for the blogging on this subject!!

    Personally, I support the American Health Information Management Association (AHIMA) recommendation for all healthcare entities meet the compliance date of October 1, 2013, for implementation of the ICD-10-CM and, where applicable, the ICD-10-PCS classifications.

    Today, HIM professionals are leading the efforts to use data to measure the quality, safety (or medical errors), and efficacy of care; making clinical decisions based on output from multiple systems; enabling the connectivity of information systems for continuity of care; designing payment systems and processing claims for reimbursement; conducting research, epidemiological studies, and clinical trials; setting health policy; designing healthcare delivery systems; monitoring resource utilization; improving clinical, financial, and administrative performance; identifying fraudulent or abusive practices; managing care and disease processes; tracking public health and risks and providing data to consumers regarding costs and outcomes of treatment options.

    It is important to differentiate the “output” systems from “input” systems or clinical terminologies such as SNOMED-CT® which are designed for the primary documentation of clinical care. Since they codify the clinical information captured during the course of patient care, terminologies can only be used in electronic health record (EHR) systems.

    Together, HIM professionals are promoting the use of current standard clinical terminologies (SNOMED) and classifications (ICD) as they represent a common medical language that allows data to be shared and must be incorporated into EHR systems in order to achieve system interoperability and to realize the benefits of a national health information infrastructure. The ICD-10-CM/PCS classification systems are the 21st century vocabulary needed to support the U.S. effort to adopt electronic health records (EHRs) and achieve an interoperable health information exchange – a goal that underpins our nation’s reform program for healthcare. Failure to have these classifications in place means that we are building systems, and the standards that support them, without having the ability to experience the expected value of data interoperability.

    The expanded availability of SNOMED-CT®, made possible by the federal government licensing agreement, increases the urgency of replacing ICD-9-CM with ICD-10-CM/PCS, so the development of mapping tools to the ICD-10-CM and ICD-10-PCS can take place.

    Replacement of the current code set, ICD-9-CM, is long overdue and the U.S. needs ICD-10-CM and ICD-10-PCS now!!


    Thanks for your comment; you are exactly right that we need to delineate the functions of the coding systems we use. I would offer one elaboration on that.

    Wes Rishel clarifies a fundamental difference, here: http://blogs.gartner.com/wes_rishel/2011/07/17/future-snomed-vs-icd-11/

    "My other concern is the fundamental difference between a classification system and a concept enumeration. Classification systems are designed to always be able to express an answer (perhaps better, perhaps worse.) The question might be “what did this patient die of, what was the regional distribution of various kinds of lung cancer” or “given the problems and course of treatment, under which of the clauses in our contract or regulation do you want to be paid?”"

    All of this reminds me of the lesson of day one of MBA accounting: There is no correct, universal way to do accounting. Different approaches need to be used based on the problem you're trying to address. Hence, Balance Sheets, Income Statements, Cashflow Statements, etc don't substitute for eachother; they address different needs.

    The outputs of a clinical encounter are the same as those accounting principles. As you and Wes elaborated, there are distinct requirements for classification and concepts systems. In my clinical specialty, Rheumatology, there's even a critical distinction between classification-for-clinical-studies and diagnostic criteria. Most patients at onset can be classified-for-study-purposes as having Lupus, even when they don't yet meet diagnostic criteria.

    ICD-10 is needed today for these and other multiple required objectives.

    Thanks again for your comment, Bonnie.