Clearing the Air on the ICD-10 Transition

AHIMA's Sue Bowman shares her perspectives on the current moment in the Journey towards the ICD-10 transition by mark haoland

When, this March, the U.S. Congress inserted a yearlong delay in the mandate for the transition from the ICD-9 coding system to the ICD-10 coding system from Oct. 1, 2014, to at least Oct. 1,2015, as part of a broader bill creating a temporary "SGR fix" (a delay in Medicare physician payment cuts under the program's sustainable growth formula), it threw ICD10 planning into disarray across the U.S. healthcare system.

At the Chicago-based American Health Information Management Association (AHIMA), the national association of health information management (HIM) professionals, the reaction to Congress'sMarch 31 action was one of shock and dismay. After the U.S. Senate passed the SGR-fix bill on March 31, and just before President Obama signed it into law on April 1 (the provision on ICD-10 had been slipped quietly into the SGR-fix bill by lobbyists representing medical specialty societies), AHIMA issued a press release saying that "The American Health Information Management Association (AHIMA) expressed deep disappointment that the U.S. Senate voted today to approve H.R. 4302, Protecting Access to Medicare Act of 2014, which included language delaying implementation of the ICD-10 code set until at least Oct. 1, 2015."

The press release included a formal statement from AHIMA CEO Lynne Thomas Gordon stating that, "On behalf of our more than 72,000 members who have prepared for ICD-10 in good faith, AHIMA will seek immediate clarification on a number of technical issues such as the exact length of the delay." It went on to say that "It has been estimated that another one-year delay of ICD10 would likely cost the industry an additional $1 billion to $6.6 billion on top of the already incurred costs from the previous one-year delay. This does not include the lost opportunity costs of failing to move to a more effective code set." It added that "The United States remains one of the only developed countries that has not made the transition to ICD-10 or a clinical modification, a more modern, robust and precise coding system that is essential to fully realize the benefits of the investments in electronic health records and maximize health information exchange."

What's more, the leaders at AHIMA have been very active in the Coalition for ICD-10, a group advocating for a speedy and comprehensive transition to ICD-10. That group includes a broad array of industry groups, including America's Health Insurance Plans (AHIP), the BlueCross BlueShield Association, the Medical Device Manufacturers Association (MDMA), the American Hospital Association (AHA), and American Medical Informatics Association (AMIA).

AHIMA strongly applauded the announcement on July 31 by the federal Centers for Medicare and Medicaid Services (CMS) that the new transition date would be Oct. 1, 2015 (the earliest day allowed by the congressional legislation), with the association saying in a statement on July 31 that "Now, everyone in the healthcare community has the necessary certainty to move forward with their implementation processes, including testing and training."

AHIMA's leaders say they continue to do everything possible to help healthcare organizations prepare for the transition, while making it clear that they will oppose any further delays, and speaking out against what they see as myths propagated by the opponents of the ICD-10 coding system.

In that context, Sue Bowman, senior director, coding, policy, and compliance, at AHIMA, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the current moment in the ICD-10 transition saga, and her perspectives on it. Below are excerpts from that interview.

LESS NEGATIVITY SURROUNDING THE ISSUE

Healthcare Informatics: In interviews I've done recently, I've heard some pushback about the usefulness of the ICD-10 system. Are you hearing any pushback right now?

Sue Bowman: Well, nothing new, really. In fact, as people become more familiar with ICD-10, their negative view is changing. People are still saying there was no clinical input in the development of the coding system; but from the beginning, all of the content of it really came from the clinical community. There's actually something called the Coordination and Maintenance Committee, co-chaired by the National Center for Health Statistics, and CMS. They're responsible for the maintenance of ICD-10 code sets in the U.S. NCHS maintains ICD-10-CM, which is a diagnosis system; and CMS maintains ICD-10-PCS, the new procedure coding system, for hospitals; so they've been guiding the development process.

It's a public process, where people can submit proposals for new and expanded codes. And so even from the development to how it's being maintained now. On the one hand, you hear people complaining about the detail and specificity of it; but it's physician organizations that want more codes-which is kind of funny.

HCI: Is it correct that ICD-10 in this country will be different from the ICD-10 systems in other countries, with 10 times the codes of other ICD-10 systems? That's what a few people have told me.

Bowman: No, that's not entirely correct. The first few digits have to be kept standardized internationally; but beyond the first few digits, codes can be expanded for your specific country's needs. Within the constructs of the code sets of the international system, you have to maintain stability in the first few characters. A lot of the specificity we've added is not new diseases; it's specific details about anatomy; but a significant percentage is around laterality-left or right side. If you can code broken left arm or broken right arm, that doubles the number of codes right there; but it doesn't add to the complexity of the system; indeed, it provides clinical clarity that speaks to patient safety. Of course, hopefully, laterality is already being documented in the medical record.

HCI: Are those expressing dissatisfaction just a few isolated grumblers?

Bowman: It's like with anything else; the negative people tend to be louder; but the vast majority of people, including physicians, is in support of the ICD-10 transition, and realizes we need to replace ICD-9 after 35 years of use. You'd think, of any country, that we'd have more motivation than anyone else to change systems, for all the reasons we use healthcare data. If you think of how things were in the 1970s-it's just a different environment today inpatient care.

MORE PHYSICIANS ARE READY TO MOVE AHEAD

HCI: Do you think everyone's pretty much ready at this point?

Bowman: Yes, and interestingly, I've heard from a number of physicians in practice who weren't happy with the delay, including my own personal physician. My physician said,' I'm the kind of guy who follows directions, and turns in his homework on time. Now I'm going to have to keep my staff trained and systems up; and so the delay is going to cost more money for everyone except for those who did nothing-why are we rewarding them?' I think we've gotten so lost in arguments that some people have lost sight of why we're doing this. We're doing this to get better data, not just for the U.S., but to share globally around things like global health threats. Healthcare today is global, just like everything is global.

HCI: Should people be doing dual coding now?

Bowman: Yes, a lot of organizations are doing dual coding to keep their coders in ICD-10 practice, because a lot of people have already been trained; otherwise, they'll forget it. Also, people are using that dual-coding data to assess reimbursement effects and payment mix. Instead of hypothesizing how ICD-10 might affect them, they can see it in real data.

HCI: What percentage of hospitals and medical groups are doing dual coding?

Bowman: I'm not sure of the exact percentage. Probably not the smaller practices; it does take additional time to dual-code. I would imagine it would be hospitals and larger practices.

HCI: Has anyone shared with you what they've done with this?

Bowman: Yes, we had something on that in a white paper that we produced after an ICD-10 summit. Obviously, this is giving people more practice in ICD-10, which means that on the transition date, hopefully, the impact will be considerably less, because they will have been coding in ICD-10 for some time at least in some records; the other thing is that the training for ICD-10 has actually improved coding for ICD-9. It's also pointed out that the ICD-9 coding isn't all that great.

When you talk about the impact of ICD-10 on coding accuracy, then you discover that actually, ICD-9 coding wasn't optimal to begin with, so the training is helping to strengthen core coding principles and practices. Some people going through ICD-10 coding training may never have had formal ICD-9 coding training. A lot of people coming to ICD-10 training just sort of picked up ICD-9 on the job.

HCI: What should CIOs know about all this?

Bowman: They should know that this isn't simply an "HIM thing." Now, certainly, CIOs should know that this is an enterprise-wide transition. Codes, underneath the surface, are driving different initiatives. When people begin doing their assessments, they have a lot of surprises about places where codes are used, not just in claims. I can send your our preparation checklist; but some things are disease management programs, where they use ICD-9 codes to identify patients; registration for medical necessity-when the patient registers, a lot of times, a code is put into the system to match data against any review policies, to make sure it will be a covered service by a payer, so, eligibility. I've even heard of things like OR scheduling systems, where the codes are used to identify patients.

REASON FOR OPTIMISM

HCI: Overall, how do you feel about what's going on right now?

Bowman: I feel pretty good. I know that with the delay, some momentum was lost. 'Ihere's some skepticism-some people think it could still be delayed again-but I've seen a lot of evidence that people are moving forward. I'm glad to see CMS come out with testing information, because that's the stage people need to get to next, 'there are a lot of strong messages out there around what needs to be done. A year seems like a long time, but it really isn't. Don't wait until the last minute.

HCI: And physicians shouldn't be afraid?

Bowman: No, they really shouldn't. There's been so much fear-mongering out there, but once physicians experience it, they say, oh, this isn't so bad. It turns out that many of the codes have been created by their own medical specialty societies, and they're still only going to be using a small subset of codes that they typically use in their area. You can still use a super-bill; you've still got your list of common conditions. All you have to do is translate the codes you use already into ICD-10 codes.

HCI: There will be more codes, but it won't be overwhelming for individual physicians?

Bowman: Right. In a lot of cases, they might find the terminology of the codes closer to how they document to begin with. An example I use is asthma. In ICD-9, it's broken down into terms like "extrinsic" and "intrinsic," terms that no physicians have used for years in documenting; instead, asthma under ICD-10-the vocabulary has been updated to terms physicians use today. And the physician community had a lot to do with modernizing that terminology.

THE VAST MAJORITY OF PEOPLE, INCLUDING PHYSICIANS, IS IN SUPPORT OF THE ICD-10 TRANSITION, AND REALIZES WE NEED TO REPLACE ICD-9 AFTER 35 YEARS OF USE. -SUE BOWMAN

I'M GLAD TO SEE CMS COME OUT WITH TESTING INFORMATION, BECAUSE THAT'S THE STAGE PEOPLE NEED TO GET TO NEXT. THERE ARE A LOT OF STRONG MESSAGES OUT THERE AROUND WHAT NEEDS TO BE DONE. A YEAR SEEMS LIKE A LONG TIME, BUT IT REALLY ISN'T. DON'T WAIT UNTIL THE LAST MINUTE. -SUE BOWMAN

A LOT OF ORGANIZATIONS ARE DOING DUAL CODING TO KEEP THEIR CODERS IN ICD-10 PRACTICE, BECAUSE A LOT OF PEOPLE HAVE ALREADY BEEN TRAINED; OTHERWISE, THEY'LL FORGET IT. ALSO, PEOPLE ARE USING THAT DUAL-CODING DATA TO ASSESS REIMBURSEMENT EFFECTS AND PAYMENT MIX. -SUE BOWMAN