The first rule of marketing is to make sure you have a clear message. For the American Medical Association leadership, their position on the impending ICD-10 conversion could not be more straightforward … they want to see it stopped.
AMA President Ardis Dee Hoven, MD, pointed to a number of issues that have members worried about the health of their practices … and ultimately their patients. Concerns range from cost of implementation and software availability to worries over disruption in pay and a siphoning of resources away from other transformative changes that improve healthcare delivery.
In a Feb. 12 letter to Kathleen Sebelius, secretary for the U.S. Department of Health and Human Services (HHS), the AMA acknowledges the position they have taken is at odds with some of their industry colleagues. Yet, AMA officials believe the timing of such a massive undertaking is ill advised and could prove disastrous for physicians.
“The challenge here is disruption — it’s a disruptive process that delivers no direct benefit to patient care,” Hoven asserted.
Many Codes Equals Much Room for Error
ICD-10 — the International Classification of Diseases, 10th Edition — was endorsed by the World Health Organization (WHO) in May 1990 and put into use by member states beginning in 1994. In the United States, the nomenclature has been modified and greatly expanded, resulting in more than 140,000 codes across patient settings.
The Clinical Modification (CM) is used for diagnosis coding in all healthcare settings and has 68,000 codes. Hoven said ICD-9-CM encompassed between 13,000 to 14,000 options. “It’s about a five-fold increase,” she pointed out. The Procedure Coding System (PCS) for inpatient settings only has 72,000 codes. Hoven said other countries have to deal with significantly fewer options. Canada, Germany and Australia all have less than 20,000 codes in their ICD-10 set, and Canada uses ICD-10 for inpatients only.
In the American system, she noted, “You’ve got to have an ICD-10 code for the disease signs and symptoms, abnormal findings, complaints, circumstances and external causes of injury or disease. The problem is the granularity of the ICD-10 codes.” She added, There’s something like nine codes for parrot bites.” The vast number of choices, she fears, makes the potential for error enormous.
Since ICD-10 accuracy is tied to reimbursement, physicians across the country are worried about the financial stability of their practices if payments are denied, delayed or otherwise disrupted.
“If it’s not correct, Medicare won’t pay you … no one will pay you,” Hoven noted. She added patients might be the ones who ultimately pay the highest price in terms of access to care if some practices simply cannot weather the financial storm. “This is why the American Medical Association has been so adamant in trying to get ICD-10 repealed.”
Hoven pointed to the results of a pilot study released last year by the Healthcare Information & Management Systems Society (HIMSS) and the Workgroup for Electronic Data Exchange (WEDI) that showed experienced coders had an average accuracy rate of about 63 percent when converting diagnoses to the ICD-10 coding system.
Conducted in 12 waves, each test series consisted of a number of different cases. While 63 percent accuracy was the overall result, individual figures varied widely within each wave. For example, in wave 6, ‘acute bronchiolitis due to RSV’ was accurately coded only 38 percent of the time. On the plus side, coding for “deviated nasal septum” had a 100 percent accuracy rating in wave 7.
Another financial issue recently came to light when the AMA initiated an updated cost study, which found the price tag for ICD-10 implementation was dramatically higher than previous estimates.
“We were basically operating on 2008 figures, and when we saw these new numbers, it was even worse,” Hoven said. In fact, the 2014 figures found that in some cases implementation costs would be nearly three times what had been predicted six years earlier. Nachimson Advisors conducted both the original 2008 study and updated 2014 version.
In 2008, the average predicted cost to implement ICD-10 was:
$83,290 for a small practice,
$285,195 for a medium practice, and
$2.7 million for a large practice.
The new cost estimates feature a range for each practice size based on variable factors including specialty, vendor and software. The updated study predicted implementation costs would be:
$56,639-$226,105 for a small practice,
$213,364-$824,735 for a medium practice, and
$2 million to just over $8 million for a large practice.
Two-thirds of physician practices are projected to fall into the upper ranges of the current cost estimates, which include training, assessment and testing, productivity loss, process remediation, payment disruption and vendor/software upgrades..
“The markedly higher implementation costs for ICD-10 place a crushing burden on physicians, straining vital resources needed to invest in new healthcare delivery models and well-developed technology that promotes care coordination with real value to patients,” Hoven said.
The Bottom Line
“ICD-10 is an unfunded mandate,” Hoven reiterated, adding it’s also one that comes with a high price tag at a time when physicians already are struggling to stay on top of other costly federal mandates.
“Adopting ICD-10, while it may provide benefits to others in the healthcare system, is unlikely to improve the care physicians provide their patients and takes valuable resources away from implementing delivery reforms and health information technology,” she concluded.
The Irony: A Win/Lose Situation
In February, AMA launched a #StopICD-10 Twitter campaign in support of the organization’s continuing effort to urge HHS to make good on its commitment to improve the regulatory climate for physicians. At the time, Hoven said she was aware that CMS officials were adamant that the deadline would not shift again and that everyone should be prepared to go live Oct. 1, 2014.
On the evening of March 31, the Senate approved a bill already passed by the House that delayed ICD-10 implementation “for at least a year.” Ironically, that win for the AMA was tacked onto a bill that patched the much-hated SGR formula for the 17th time, as opposed to permanently fixing the problem as the AMA has long requested.
And One Final Note
While the debate rages on over ICD-10, it should be noted work on developing ICD-11 has already begun and is expected to be ready for WHO approval in 2017.