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When in doubt, do the right thing

April 16, 2009
by Joe Bormel
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When in doubt, do the right thing.
You'll be surprised. You usually will know what the right thing to do is.
You'll also know why you don't want to do it!
Do the right thing.

--- Steven Muller

That was a bit of advise offered to my graduating class by my university president. Over the last several decades, the advice has rung all too true.

Today, as I listened to presentations about ICD-10, given by CMS, a payer, provider-based HIM professionals, a CIO, a Gartner analyst, and others, I heard that ICD-10 is

the right thing to do. The case is very compelling, and well documented by


ICD-10 has been adopted by every other country on Earth. It can dramatically improve our ability to retrospectively understand the care that's been delivered relative to what's possible in ICD-9.

To put things in perspective, ICD-10 has a quality identical to the Y2K situation we faced a decade ago. ICD-9 codes are embedded, nearly invisibly, in dozens of systems that are mission critical today. Interfaces are built with the expectation of ICD-9 formats, which are shorter and have different rules for padding and placement than ICD-10. Therefore, a comprehensive inventory of information systems is necessary as part of the planning process.

Why is ICD-10 different in the USA? Here is the conundrum. Although the rest of the world has successfully migrated to ICD-10, the U.S. will be the first country to go there. Why?
Because the U.S. healthcare system is unique, and the unspecified (or underspecified) payment reform inherent with converting to ICD-10 gives rise to economic issues which are not prominent elsewhere in the world.

The economics (complex payment systems) of healthcare delivery in the U.S. are integrally connected to ICD-9. These are unlike most, if not all other countries, that are using ICD-10. The result is

there is no precedent to comfort or assure us that there will be no surprises. How can we avoid unexpected consequences to ensure that fair, reasonable, and equitable payments will occur for providers and payers after the conversion?

The answer is to require careful monitoring, communications, and shared, explicit expectations.

If you have any doubts about the multi-year process work to get to ICD-10, do your homework. Then, do the right thing.

Thanks AHIMA (American Health Information Management Association) for a great ICD-10 Summit and Sue Bowan, RHIA, CCS, Director for Coding Policy & Compliance for this Resource/Reference List:

Resource/Reference List


National Center for Health Statistics ICD­10­CM

Centers for Medicare and Medicaid Services ICD­10­PCS

Final Regulations for ICD­10­CM/PCS

Adoption and Modifications to Electronic

Transaction Standards



Joe. Many say that the payer databases are a great place to start for the basis of a patient EMR. But then they realize that the information in there is garbage (we have heard about the recent BIDMC-Google issues). Would not ICD-10 go a long way to making that information more usable? I know that it will never be the same as clinical data, as physicians often have to fudge the codes so an insurer will pay for a test the doctor feels is medically necessary (make up a symptom, etc). So while it may never be completely usable, at least it can be better. No?

Anthony,  Thanks for your comment.
You're exactly right. The goals include improving classification, adding specificity, as well as adding new concepts (like 'underdosing').

I think Wes Rishel captured the way to think about conversion to ICD-10 best.  He said (several times), this needs to be a two-phase thought.  Phase one - prepare to survive the crisis of the conversion.  Phase two - prepare to benefit as a result.  Plan for both phases!

The other Wes quote I really appreciated was:  "There's no reason to hear 'it is too late to do it right.' "

Dr. Bormel,

I guess I wasn't the only one at the Hopkins graduation who heard what Steve Mueller said that day. I have remembered it for nearly thirty years (although maybe President Mueller repeated it at several graduations, I don't know).

Recently, I was asked to deliver a graduation address ... and figured that was a great quote around which to build my talk. It's the only thing that anyone ever said from all of the graduations I have attended that I can actually recall . I Googled it to see if there was an original source besides Mueller and saw your blog and your reference to Mueller's quote. Pretty neat. Just thought I'd let you know someone else has hung on to it, too.

Best wishes, ... [name withheld ]