4 contentious topics in the ICD-10 debate

by Healthcare IT News

Fighting words were heard from both sides of the ICD-10 debate after the AMA called for a delay of the Oct. 1, 2013 deadline for conversion. LinkedIn and Twitter were bustling with yea or nay responses, which is why we asked Steve Sisko, IT consultant and avid ICD-10 blogger, and Rob Tennant, senior policy advisor at the MGMA, to weigh in.

1. The effect ICD-10 implementation will have on physician practices.  


It won’t be as bad as they think. According to Sisko, some practices will be burdened more than others with the switch to ICD-10. “But specialists only need to learn a subset [of codes],” he added. “They say ’70,000 ICD codes we’ll have to know,’ well, that’s BS because if you’re an orthopedic surgeon, there are subsets you don’t need to know; you don’t need to learn about other specialties’ codes.” He added, though, facilities will be impacted to a greater extent than professionals, due to the fact institutions have to collect, “Present on Admission and discharge diagnosis that professionals do not have to collect. They’ll have to lean on existing resources or hire external assistance.” 

However, he argues the transition is worth it, since, “ICD-10 will facilitate capture of accurate and complete documentation in a patient’s medical record. [It] will obviate the need for certain ‘procedure code modifiers,’ which can be confusing and lead to payment delays and increased administrative costs.” Additionally, according to Sisko, ICD-10 will enable practices to develop best practices as they get a better understanding of their costs and appropriate contracting rates. Not to mention, the transition will help practices develop enhanced care models based on comparative effectiveness research. “As time goes on, emerging CDI tools and EHR-functionality should make coding easier and more automated based on structured and semi-structured data contained in the EHR,” he added. 


It’s too much too soon.  Tennant argued the current financial environment doesn’t lend itself well to the implementation of ICD-10. “It’s impacting physician practices,” he said. “Patients have also lost their health insurance, so there’s two things with that. One is potentially fewer patients because they won’t come to the doctor’s office, and two it means when they come and they self pay, you’re shaking the money more and it goes to collections, which adds additional costs to practices.” Tennant added the looming Medicare cuts, which include more than a 27 percent reduction in Medicare payments, makes now a very uncertain time to look to ICD-10. “It’s not the best time, especially when we estimated it could be to the tune of $84,000 for a three-physician practice to move to ICD-10, not including any costs associated with 5010.” 

Barbara Aubrey

In our LinkedIn Group, ICD10 Watch, LinkedIn user Barbara Aubry echoed Tennant’s sentiments. “In Six Sigma, there is an acronym known as WIIFM, or what’s in it for me?” she wrote. “So far, I don’t think physicians believe there is much benefit to them or their patients to convert to ICD-10 – certainly not in the near term.” She added physicians are getting tired of “being pushed around by regulators and regulations.” Most, she wrote, did not go into medicine to be forced to run their business in a highly regulated environment. “Remember, many are small business owners, and they may have an entrepreneurial personality,” she wrote. “The changes are costing them time and money. I also think the AMA’s timing is quite exquisite, actually.” Twitter user @payerslayer agreed with both Aubry and Tennant and tweeted the transition affects the administrative costs of healthcare. “The U.S. cannot afford to make this change. Codes don’t cure patients,” she wrote. 

2.  What the delay of 5010 says about ICD-10. 


It gave the AMA a boost and nothing more. The HIPAA 5010 three-month delay sparked some interesting discussions in regard to its impact on ICD-10. According to Sisko, “the fact that CMS delayed 5010 for three months blew a little optimistic wind into the AMA’s sails.” He added, “It’s a sensitive subject with the AMA, and the funny thing is, the AMA only represents a quarter of the decisions,” Sisko said. “I don’t blame them if I was forced to do something and I wasn’t getting paid for it initially or directly, I’d balk too.” The question Sisko posed, though, is why so late in the game? “I think that this thing with the 5010 being delayed probably bolsters their opinion…it did make them more optimistic, and I think the timing of their position relative to the CMS delaying 5010 was dumb luck because they knew more and the whole timing-is-everything concept.”

ICD10 Watch group participant Judy Monestime agreed. She wrote the industry is already at risk with 5010 compliance. “During a presentation…to a local professional organization, I asked how many people have completed the ICD-10 Impact Assessment at their organization,” she wrote. “Only two out of the 40 plus audience members raised their hands…many in the audience believed that the go live data of Oct. 1, 2013 will be pushed back, however, CMS representatives have constantly said the deadline isn’t changing, and really too many good reasons exist for the switch.” Twitter user @MedGrpAdvisors agreed with Sikso and Monestime. “#HIPPA #5010 grace period doesn’t let #physician practices off the hook,” they tweeted. “#ICD10 preparation should still be in progress.”


It shows the US is too far behind in 5010 to think about ICD-10. “I’ll liken 5010 to a grain of sand where ICD-10 is a beach,” said Tennant. “It’s difficult and challenging, but it’s dwarfed with the difficulties associated with moving to ICD-10.” The fact that providers have struggled to get their billing and practice management systems updated, along with the fact the industry as a whole is behind in that area, doesn’t bode well for the change to ICD-10, he said, “because ICD-10 is all of what 5010 is in terms of the software upgrade, and then, it’s much more complicated in terms of the impact on the clinical and administrative side of the practice."

He added the AMA vote was indeed an indication that the landscape of 5010 and ICD-10 has changed. “But I’d say that you have to look at the broader environment in which physician practices operate in an enormous number of IT and other types of mandates,” he said. “There’s also the various IT incentive programs that are morphing into penalty programs. You’ve got the challenge of meeting meaningful use and updating technology to meet the requirements of the program as well.” 

3. The United States would be behind the rest of the world if we delayed. 

It’s true. In our conversation with Tennant, he brought up a common misconception among ICD-10 supporters in the United States, which is we’re the last country to adopt the code set. Upon further digging, we saw this was true and found examples from ICD10 Watch LinkedIn group members, Anthem Blue Cross Blue Shield fact sheets, and more:

  • Judy Monestime wrote in an ICD10 Watch post, “The United States is 10 years behind Canada and even farther behind Europe!!! The transition to ICD-10 is well overdue!”
  • A frequently asked question sheet, posted online by Anthem Blue Cross Blue Shield read, “Yes, most other countries are already using a version of ICD-10. The United States is the last industrialized nation to adopt ICD-10.”
  • The AAPC listed in a fact sheet that, “ICD-10 is a diagnostic coding system implemented by the World Health Organization (WHO) in 1993 to replace ICD-9, which was developed by WHO in the 1970s. ICD-10 is in almost every country in the world, except the United States.”
  • Saince, which provides IT, HIM and business process outsourcing services to clients globally, wrote on its site, “The U.S. is the only developed country that has not adopted ICD-10. Of course, cost is a factor for the adoption delay, but waiting will only increase future implementation costs. But reduced healthcare costs will result once a more specific coding system like ICD-10 is adopted.”
  • And a 2008 transcription of a Centers for Medicare & Medicaid Services ICD-10-CM/PCS National Provider Call for Hospital Staff showed speakers stating, “Though ICD-10-CM is currently not in use for any purposes in the U.S., several countries have either adopted or adapted some of the modifications that have been made in ICD-10-CM. Countries that have so far adopted ICD-10 or a clinical modification for use in either reimbursement or case mix include the United Kingdom, which was the first country in 1995, leading all the way to Canada in 2001.”


Not quite. “You may have heard we’re the last country to move to ICD-10,” Tennant said. “I’m sure some of the folks were saying that, and that’s a complete fabrication. It’s interesting because even providers around the country, they just assume that’s correct because so many people have said it, but that’s not the case.” In fact, said Tennant, we’re the only country to use ICD-10-CM, which is the largest code set of any country. “Just to give you some perspective,” Tennant continued, “The Canadian version of ICD-10-CA has only 17,000 codes; already, ICD-10 CM, the American version, has 69,000. What they don’t tell you is Canada took many years. They started in 2001 and didn’t finish until 2006.” But what’s most interesting, said Tennant, is Canada chose not to move to ICD-10 on the ambulatory practice side – only on the hospital side. “I bet you haven’t heard that,” he said. “It’s a lot of disinformation floating around the industry on ICD-10: the fact we’re woefully behind the rest of the world.”

4. How more accurate coding will affect patient care. 


It will ensure providers are doing what they should have been doing all along. According to Sisko, ICD-10 will increase first pass adjudication rates, resulting in faster claims payment and less administrative hassle for providers and patients. “Enhanced documentation of a patient’s clinical condition can only improve care and will enable a more accurate means of sharing information with other caregivers,” he said. “More specific diagnoses codes and more accurate definition of procedures performed will be the Lingua Franca for HIE’s.” More accurate coding will facilitate auditing efforts, reduce time related to RAC inquiries, and should decrease ability for fraudsters to game the system, he added.

“The other thing is bilaterally, left to right. So you have a broken leg and it’s the second time you’ve been to the doctor versus the first time. The second time the payment for that should have been bundled with the first. So, they’re taking these two elements, which are combinations of the single code, so of course it increases the code set, but providers should have been collecting this info all along. They’re grousing this is an extra burden. Well, it shouldn’t be.” ICD10 Watch participant, David Saintsing, added a broad clinical and informatics view and analysis, “would show that ICD-10, from a patient outcome perspective, would improve over time the standards of care for a particular illness, as we, as scientists, get a greater level of detail.”


We don’t know enough to implement ICD-10. “The quality of healthcare would not change at all,” said Tennant. “This is a change in code set.” Tennant referenced the Wall Street Journal article, which took a humorous look at all the irrelevant codes associated with ICD-10. “I think that was one of the catalysts for the vote by the AMA; it talked about being bit by a turtle or walking into a lamp post or being burned if your water skis were on fire. But should we be basing our reimbursement coding system around that? No.” He added one of the arguments is we don’t get to the granularity available to ICD-9. “There is something called unspecified, but virtually, in every category, there is the ability to code unspecified, or you can select a more detailed code.”

The question is, said Tennant, will physicians code to this more granular level? And if they don’t, then will we gain the advantage of moving to this new code set? “And if they do, what will be the payment policies of the health plans, including Medicare, for example. Maybe health plans require the most granular codes and other ones will accept unspecified. So the payment policy issue is one of those great unknowns, and health plans have not yet been announcing their payment policy. That is one of those issues that will have a tremendous impact on physician practices.”

Follow Michelle McNickle on Twitter, @Michelle_writes