Sunday, March 9, 2014

Way back in 2008, my friend and colleague John Halamka wrote this post about the transition from ICD-9 to ICD-10 codes, the codes that are used to record clinical activity for the purpose of reimbursement by Medicare and other insurers. John is the unquestioned national expert in health care IT systems. At the time, he was "enthusiastic about the adoption of new standards that enhance semantic interoperability. The use of modern vocabulary standards such as ICD-10 improve administrative efficiency, enhance the ability of decision support systems to enforce guidelines, and enable a more granular reimbursement process." But, he also pointed out the logistical and training problems inherent in this kind of transformation:

The overall cost of implementing this change is technological and operational. For example, there must be modifications to existing training curriculum as well as claim submission and payment policies to ensure no adverse impact to the revenue cycle. I anticipate a real challenge to train, recruit, and retain ICD-10 savvy coders.

Well, that may have been one of the biggest understatements in health care for the decade.  As I have traveled the country, few issues have raised more concern than this one. 

By 2011, John Halamka was warning us:

If Congress was doing its job of regulatory oversight, they would sponsor hearings to learn what payers and providers are actually spending on ICD-10 conversion. Costs for consulting services alone run into the millions. This does not count the application software conversion, training and education, and other "in-house" costs. At our medical center, we would be paying $380,000 according to HHS estimates. Instead, the marginal cost of ICD-10 will be in excess of $5m. For multi-hospital systems, the costs may exceed $100m.

A Congressional review of transition costs would turn the regulatory impact assessment on its head. Costs could easily become double the estimated benefit savings.

With ICD-10, the government is perpetuating a reimbursement system that is far too complex. We spend more than any other country on healthcare administrative overhead. The Medicare Claims Processing Manual, for example, is over 4,000 pages in length. The reimbursement system needs simplification to bring the cost of this function in line with other industries.

In 2013, he noted:

We learned from that end to end testing with a full user load and complete data set is important to validate the robustness of an application. ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away. Does CMS have time for a full end to end test of all functionality with its trading partners? I am concerned that not enough time is available. Will most payers and providers be ready to process transactions on October 1, 2014? Maybe. Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place? Doubtful. Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign? Certainly. The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US. The consequences of a delay in enforcing ICD-10 use are minimal.

There have been lots of similar requests to the government to slow this down, but the CMS administrator is holding firm to the latest deadlines:

Providers, payers and claims clearinghouses can look for no relief from the looming, Oct. 1 compliance deadline for the nationwide conversion to the ICD-10 family of diagnostic and procedural codes, the head of the CMS said Thursday.  

Tavenner's comments triggered a quick, and apprehension-filled, response from the American Medical Association.

“The AMA is deeply concerned that Medicare does not have a back-up plan if last minute testing demonstrates anticipated problems with this massive coding transition,” said AMA President Dr. Ardis Dee Hoven.

Many doctors are still awaiting software updates from vendors and risk not having sufficient time to test those updates when they finally do arrive, Dee Hoven pointed out. “Testing is needed to discover problems and resolve them prior to the go live date. The slightest glitch in the ICD-10 rollout could potentially cause a billion dollar back-log of medical claims that jeopardizes physician practices and disrupts patients' access to care,” she said.

So, the training goes on.  Barnes Jewish Hospital in St. Louis, for example, has prepared thousands of "tip" cards like the ones above to help people remember some of the details required under the new coding environment.

Meanwhile, this has become a big business.  Here in Boston, one IT firm is even advertising on public radio (!) that is it available to help health care facilities manage the transition.  (I guess that just shows how many health-care-related NPR listeners live here!)

I guess this is all necessary, but I'm not sure I really understand why.  For example, if the trend in the US really is towards global, or capitated, payments, why do we need record-keeping of such detailed clinical activities?  Also, this new required level of detail creates immense compliance risks for doctors and hospitals and enforcement needs for regulators. It seems to me that the chance of inadvertently coding something wrong has just increased by two or three orders of magnitude.

 The CDC summarizes:
  • There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3
  • There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM
  • ICD-10 has alphanumeric categories instead of numeric ones
  • The order of some chapters have changed, some titles have been renamed, and conditions have been grouped differently
Given the government's recent focus on enhanced billing compliance, we can expect many more investigations and financial penalties.

I'd prefer that providers be allowed to spend more time calling their patients and talking to them about their conditions rather than coding their illnesses.

Meanwhile, there is some humor in the situation:


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