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A 10 Beats A Nine, No Matter How You Cut The Cards

September 16, 2008
by Joe Bormel
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Accepting the Inevitable is No Way to Implement ICD-10

Those who have long fought the transition to and implementation of ICD-10 in the United States are now quickly being silenced by the forthcoming government mandate for providers and payors alike to move forward with this long overdue improvement to our healthcare system.

If you haven’t yet read the two recent blog postings to this site concerning ICD-10 by

Reece Hirsch and

Mark Hagland, I suggest you do so. They have some very insightful things to say on this subject.

Over the past several weeks, I have tried to become “smarter” about ICD-10. To a great degree, my efforts have been rewarded with a troubling deluge of information about the billion or so dollars it will cost to transition from the existing 30-year old ICD-9 coding methodology, the problematic learning curve, and the potential for interim reimbursement problems. But what has troubled me most is an overriding position expressed by many highly reputable experts that we might as well shrug our shoulders, accept the inevitable and prepare for the worst. Now I ask you, is that any way to efficiently and effectively manage change?

Five years from now, the arguments against ICD-10 will be as laughable and ridiculous as:

• MS-DOS works fine, why Windows?

• X-rays are sufficient.

• Who needs air bags when we have seat belts?

• Cell phones are just a novelty.

• Louis Pasteur's theory of germs is ridiculous fiction.

• Airplanes are interesting toys but of no military value.

• Drill for oil? You mean drill into the ground to try and find oil? You're crazy.

• With over 50 foreign cars already on sale here, the Japanese auto industry isn't likely to carve out a big slice of the U.S. market.

• While theoretically and technically television may be feasible, commercially and financially it is an impossibility.

• There is no reason anyone would want a computer in their home.

• Sensible and responsible women do not want to vote.

Gartner has called the transition to ICD-10 “a momentous change.” However, it also states that, “In the long run, ICD-10 is a key enabler for quality improvement, better management planning and better care.” Better care, isn’t that what every provider organization is trying to achieve?

For more than a decade,

AHIMA has warned of the problems that exist with the ICD-9-CM system, while

artfully promoting the value proposition of ICD-10. The AHIMA site offers a wealth of information from which CIOs and other senior executives can benefit.

We need first to understand some of the baseline deficiencies inherent as we continue to use the ICD-9-CM system. ICD-9-CM is obsolescent. The system is quickly running out of space for new codes, thereby limiting the inclusion of new procedures and diagnoses. Further, it is not sufficiently precise to fully enable an EHR, conform to pay-for-performance reporting requirements, adversely affects DRGs by grouping different procedures into a single code, and decreases our already considerable investment in SNOMED-CT.

Additionally, because ICD-9CM is imprecise and uses terminology inconsistently, not only is it difficult or impossible to capture new technology, the system lacks the codes necessary to cover preventative services. This hinders the progress of personalized medicine, and discourages the use of advanced diagnostic testing. I suggest you read “

Realizing the Promise of Personalized Medicine” in the Harvard Business Review to learn more.

We now have the gist of the current problem, so let’s get an overview of the ICD-10 solution. According to HHS, as we adopt ICD-10 code sets, we can expect to realize:

• More accurate (and realistic) reimbursement for new procedures with fewer rejected claims, better disease management, and standardized international disease monitoring and reporting.

• Support for comprehensive quality data reporting.

• Value-based purchasing based upon accurately defined services providing specific diagnoses and treatment data that should speed reimbursement while deterring Medicare fraud and abuse.

• Enable us to compare U.S. data worldwide to track the incidence and spread of disease, as well as treatment outcomes.




Dr. Joe,
Thanks for steering us in the right direction. Speaking only for myself, having someone like you speak up about the need for responsible change management is a giant step forward. The transition to ICD-10 is a great example, but certainly not the only one we could note in HIT.

Not being a member of the HIM community, I appreciate your emphasis on reviewing what AHIMA has to offer on the subject. If we had only listened to these folks ten or so years ago, we wouldn't be facing a rediculous mandated deadline today. There is a wealth of information on the AHIMA site.

Further, I downloaded the Rand study. It was published four years ago! Makes one wonder why there wasn't wider distribution through promotion, etc.

I don't know about you, but I'm tired of so-called "professional organizations" that keep surpressing technological advancements in the healthcare industry until we bump up against multiple government mandates for implementation of HIPAA, the EHR, ICD-10, etc., in a short period of years.

The fact is, we could have phased in much of the technology we need to improve care and become more patient centric if we had not received so much "expert" advice, and pressure to remain status quo.

I sincerely hope you and the others who contribute to this site maintain the backbone to speak out for what we should be doing, without hesitation when it comes to telling us what we should have done. Thank you.

Thanks for the insight into ICD-10. It is difficult to imagine that the US is so far behind other countries in this regard. Hopefully this transition will not be as difficult as some would have us believe.

WSJ, November 11:
Why We Need 1,170 Codes for Angioplasty

  Here's a brief excerpt:

Hospitals, insurance companies and many doctors say the planned coding system is necessary to keep up with the host of new medical developments that emerge every year. The new system, known as ICD-10, would sharply increase the number of codes used to define various ailments and procedures to 155,000, nearly 10 times as many codes as are currently in use. Today, for example, there's just one code -- 39.50 -- for angioplasty, a procedure used to widen blocked blood vessels; under the new system, medical practitioners can choose among 1,170 coded descriptions that pinpoint such factors as the location and the device involved for each patient. ...

Of course, some of the most insightful observations are found in the comments tab (just like wikipedia).  In this case, commenter Calvin Tong pointed out that the current codes are used today (in all industries) for very gross accounting reasons.  The cost of the additional specificity may not beneficial to the patient, provider, clinicians, finance, or operations.  Especially true as number of codes go up.

This suggests that a holistic or systems approach to moving to any new coding system (and also true of ICD-10) would involve a re-look at documentation (especially usability) and the payment model.  Today, our doctors pick codes based on what they know will be reimbursed and not rejected.  Increasing the number of codes and not addressing these code use issues have obvious outcomes.

Jack, you're absolutely correct. I'd refer you to Wes Rishel's article "U.S. Care Delivery Organizations Should Use These Steps to Prepare for ICD-10, " available from Gartner (subscription or fee). He cites that prior experience in Australia showed that coders were able to adjust to pre-conversion productivity levels in about 12 weeks. But the story is a little more complicated than that. Worth reading Rishel. -Joe

Great post, Joe. This is very timely and as an HIM professional, I'd like to thank you for the (well-deserved) AHIMA plug. I agree that the transition to ICD-10 will result in better data, and the outcome will be better care. Do you have any thoughts on the related X12, version 5012 standard?

Thanks for the kind words and the 'dose of reality' about ICD-11. You summarized the situation well. It's time, now, to exploit the ICD-10.

I'd like to re-iterate for readers that the AHIMA web site (references in my original post) are outstanding and balanced.

After venting yesterday, I've now had a chance to review all your links, which led me to still more in the process. I'm a little confused.

Although 2011 is the target for ICD-10 transition, it appears that few providers or payers will be ready to fully implement the system at that time, and it may take up to three more years to get everything operating smoothly. Is this correct, or can you clarify things for me?

Laney, Thanks. I'll try to get some sight on X12 v5012 and get back to you.

Joe - Thanks so much for the post. Let me add a few thoughts on the idea floating in some circles that we should just wait for 2011. We've been tracking the development of 11 closely, and there's simply no way it will be ready for 2014. No firm timeframes for the completion of developmental work or testing on ICD-11 have been set, and work hasn't yet begun on developing the companion procedures codes needed to implement it in the US. We're estimating the earliest possible date for ICD-11 to be 2020, so given the moribund state of ICD-9-CM, it's time to move forward with this change. We know change is difficult, and it's especially challenging for some segments of our industry, such as smaller physician practices. But I can speak for AHIMA when I say that we're developing the tools and resources to facilitate this transition for our members and the industry, so we can all reap the healthcare benefits of quality data.

Jill Dennis