March 26, 2012

Another dragon is slinking away, although it isn’t yet slain.  On February 15, 2012, Health and Human Services Secretary Kathleen G. Sebelius announced that “HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).” In other words, medical practices no longer need to ensure that they will be ready for ICD-10 by October 2013.

The press release noted that the final regulation adopting ICD-10 as a standard was published in January 2009, and that it set a compliance date of October 1, 2013 (itself a delay of two years from the compliance date initially specified in the 2008 proposed rule).  HHS has not given any hint regarding a new compliance deadline. 

ICD-10 is a set of codes used to identify and describe diagnoses (ICD-10-CM) and procedures (ICD-10-PCS), replacing ICD-9. It will expand the number of codes in use from around 18,000 in the current ICD-9 code set to about 140,000.  Physicians will use ICD-10-CM to report diagnoses only; they will continue to report procedures with CPT™ codes, although hospitals will eventually identify medical services and procedures with ICD-10-PCS.  There are 13,000 diagnosis codes in ICD-9. ICD-10 contains about 68,000. The ICD-9-CM codes are only 3-5 digits long, and the alpha characters are limited to the letters V and E.  The ICD-10-CM codes contain 3-7 alphanumeric characters. The greater number of digits and possible combinations allow identification of the body system, procedure, body part, laterality, approach, and any device involved in the surgery.  The ICD-10-CM code set is more flexible for expansion and for the inclusion of new technologies and diagnoses.

The ICD-10-CM code set recognizes advances in medicine and uses current medical terminology. The code format is expanded, which means that it has the ability to include greater detail within the code and thus provide more specific information about the diagnosis. It is hoped that more specific, detailed coding will facilitate better identification of diagnosis trends, public health needs and epidemic outbreaks—and also result in fewer rejected claims and more useful quality tracking and benchmarking.

Changing over from ICD-9 to ICD-10 is obviously a very complicated business.  In urging CMS to delay the switch, AMA president Peter W. Carmel said:

The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care. At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records into their practices. 

(“American Medical Association No Fan of ICD-10,” Amednews.com, November 15, 2011.  At its interim meeting last year, the AMA House of Delegates voted to oppose the adoption of ICD-10 in the United States.)

A new deadline for implementation of ICD-10 is anyone’s guess.  A precondition is the adoption and use of Version 5010 of the HIPAA electronic transactions standard.  As noted in last week’s Alert, HIPAA covered entities including physicians and payers do not need to switch over from Version 4010 to Version 5010 until July 1st; CMS just granted another three-month delay through June 30^th in enforcement of compliance with the new standard. 

In his letter to CMS commenting on the proposed ICD-10 regulation dated October 15, 2008, then-ASA president Jeffrey Apfelbaum, MD wrote, “ASA strongly believes that the implementation date for ICD-10 should be contingent on a successful conversion to Version 5010. We agree with others who have determined that a smooth and successful transition to ICD-10 will require a three year period that can start only once the 5010 conversion is complete.”  A three-year postponement from the 5010 enforcement date will take us to July 1, 2015.  The World Health Organization, which maintains the ICD system, is developing ICD-11, and publication is anticipated in 2016, however.  ICD-10 will be obsolescent on the day it becomes compulsory—unless CMS decides to skip the Tenth Edition and go straight to ICD-11.

Without going so far as to suggest that CMS skip over ICD-10, the authors of a new article, “There Are Important Reasons For Delaying Implementation Of The New ICD-10 Coding System,” appearing in the March, 2012 online issue of the influential journal Health Affairs, noted the imminence of ICD-11 among numerous factors that favor delaying implementation of ICD-10.  Other factors include:

• Provider adoption costs, estimated by CMS to be 0.03 percent of revenue.  “In contrast, anecdotal estimates suggest that implementation costs could be an order of magnitude higher—a palpable unfunded mandate.”  The AMA has pegged the costs of implementing ICD-10 anywhere from $83,000 to $2.7 million depending on the size of the physician practice.  (“AMA calls on Congress to block ICD-10 mandate on doctors,” Amednews.com February 6, 2012.)
• Less particularity in the ICD-10-CM codes than it would appear.  Only 30 percent of its 68,000 codes, or roughly 20,000 codes, relate to disease entities.  The other 70 percent are ascribed to injuries, health status, or services, or serve to identify laterality or first versus subsequent encounters.  “In the course of most usual care, such rich and varied coding options may simply amount to clutter.”
• ICD-10 is no longer up to date.  It is based primarily on the international version of ICD-10 that the World Health Organization published in 1990.  It does not account for the impact of genomics, for example, on health care.
• The functional capacity of ICD-10-CM is not materially different than that of ICD-9-CM.
• Phase 2 of the Electronic Health Record incentive program meaningful use regulations require use of the Systematized Nomenclature of Medicine—Clinical Terms, or SNOMED CT—not ICD-9 or ICD-10—for clinical problem lists.  ICD-11 is tightly linked to SNOMED CT.

The article concludes that “the ICD-10-CM conversion is expensive, arduous, disruptive, and of limited direct clinical benefit.”  Given, however, that ICD-9 has simply run out of room for new codes and that there must be a replacement, as well as the reality that many payers, providers, and systems vendors have already invested heavily in ICD-10 projects, the adoption of ICD-10-CM must go forward.  The authors recommend “a delay period, with full adoption and use by all stakeholders by 2015.”

It seems reasonable that CMS might choose a 2015 date when it announces a new deadline for ICD-10-CM implementation.  We are not projecting a new date, though.  Instead we refer readers to materials published elsewhere on preparing for ICD-10, including our own Alert of August 9, 2010, Jason Byrd's and Sharon Merrick’s article “Delayed or Not: ASA Will Help You Transition to ICD-10” in the October 2008 issue of the ASA Newsletter, and various guides published by the American Association of Professional Coders.  We would also like to reassure ABC clients that we will be ready for the change to ICD-10, whenever it occurs, and that the change will not involve any additional charges.  We hope to help make the transition as smooth as possible for the entire anesthesia community.

With best wishes,

Tony Mira
President and CEO