Author: Jason Gottlieb

ICD-10 is the Pathway to Big Data in Healthcare

Jason Gottlieb

by William Rusnak, MD

See full article here

If big data in healthcare is the future for medicine, then ICD-10 is the way to get there.

Forgetting the idea that this coding system is largely designed for better billing and that providers will eventually be forced to make the switch, let us take a look at the benefits of ICD-10.

Although I’m well into my medicine career, I still think of myself as a struggling musician — a guy’s got to dream. Anyway, when recording in a studio, artists know all to well that when it comes to sound, poor-quality equipment will produce poor-quality audio, despite the development of truly impressive recording software. The same goes for medical data. The current coding system, ICD-9, is inflexible and far from comprehensive. “Garbage in” is a great way to describe it.

ICD-10 is an enormous expansion and at first glance seems excessive. Realistically, though, there is a finite amount of actions that a provider or patient can perform — or have happen to them. ICD-9 doesn’t even come close to meeting the descriptive needs of today’s environment. Alarmingly, there isn’t a code for Ebola. ICD-10, on the other hand, has 68,000 codes available for recording any diagnosis we can possibly imagine (plus ~72,000 more for procedures). Yes, it is comical and almost insane that some of the codes exist — see struck by a turtle and injured by a spacecraft — but that’s what being comprehensive is all about. Very often, physicians will conjure up the most unlikely, rare diagnoses for their differentials, but if they aren’t thinking about these “zebras”, they’ll never detect the one-in-a-million disease when it matters.

Ultimately, we are now in the world of “big data”, though very early in this new era. Our computing power is more than enough to adequately record human behavior in vital situations like receiving medical treatment and we need to capitalize on it. If a patient suffers the rarest of occurrences or undergoes an abstract procedure, there should be a code for it. Likewise, when a physician performs a specific procedure, a code should represent it in detail, including any variations. The first leap into big data is collecting it and that needs to be done with precision. Quality in, quality out.

We need to measure it to fix it

Some of the greatest success has been achieved by “going with the gut,” and often that is all a person can reply upon when making a decision. However, if there is a choice between proceeding blindly or having a team of scouts handing you an organized report detailing the outcomes of similar situations, most people will choose the latter. When decision-making is needed, life is simply better with data. If used properly, it can shed light upon complications within our systems that we otherwise would have overlooked. Google goes as far as saying that analyzing data will make us smarter, allowing us to anticipate problems before they occur.

As an example, look at nutrition. From my experience, when asked, many people will tell you that they “eat a pretty normal diet.” Now, make a decision with that data. Not very helpful, is it? Sure, a quick glance at the person can provide you with an answer like “it looks like it’s working,” but what advice can a physician or nutritionist possibly give without having the necessary details of the person’s diet? The same holds true for the rest of medical practice. Without measuring everything that we are doing in healthcare, improvement of our systems is going to be excessively difficult. A bird’s-eye view will be achieved when every medical organization in the country — eventually the world — is tracking events and outcomes with ICD-10. Only then will we have enough information to begin making the impactful changes needed to mend today’s broken system.

Public health, research, and quality improvement

As we finally move into this era of big data, consider the implications on public health and research. If our healthcare system is accurately collecting information about diseases and treatments in the form of codes, access to patient charts wouldn’t even be needed. The data would already be clean and organized, a scientist’s dream. Relationships between outcomes and treatments would quickly be revealed, allowing for optimization. Developing epidemics could be spotted significantly earlier. We will be able to learn in weeks what used to take years.

Last, data overload is a valid concern, but technology will help to “filter the noise” and facilitate the creation of plentiful, pertinent, organized, actionable data (not quite as catchy as “big data”, I know). Physicians will enjoy the luxury of practicing evidence-based medicine while the data unfolds in real-time. The old way of “keeping up with the literature” by reading medical journals each month will become extinct.

Big data is the future and for medicine, ICD-10 is the way to get there.

ICD-10 delay appears DOA in Congress this year

Jason Gottlieb

by Joseph Conn & Paul Demko

A proposal to delay implementation of ICD-10 diagnostic and procedure codes by an additional two years appears to be going nowhere in the current lame duck session of Congress.

“That’s not going to happen,” said a veteran healthcare consultant who tracks the issue closely, speaking on background. “The reports of them ever getting traction were overrated.”

The Texas Medical Association has been lobbying for the two-year delay. The nation’s largest state medical society for physicians, with 48,000 members, wants to push back the adoption date for the oft-delayed change to 2017.

The association’s position apparently found a champion in Rep. Pete Sessions (R-Texas), a nine-term incumbent who currently chairs the House Rules Committee. Sessions raised the possibility with House leadership of including such a provision in the budget agreement—what’s being billed the “cromnibus”—to keep the government funded, according to sources familiar with the discussions. Sessions’ office didn’t respond to a request for comment about the issue.

The federal government is set to run out of money Dec. 11 if Congress doesn’t authorize additional spending, making a funding bill a perfect vehicle for attaching special causes such as an ICD-10 delay since the overall bill must pass to keep the government open.

But the proposed ICD-10 delay, which would infuriate other interested healthcare parties that have been moving forward with plans to implement the coding changes next year, doesn’t appear to be going anywhere.

“(Sessions) definitely did make a play for it,” said the consultant, who has spoken with staffers in the offices of both the Republican and Democratic leadership. But “we are being told it is not going to happen.”

Coalition for ICD-10 Responds to AMA President Dr. Robert Wah

Jason Gottlieb

In his recent speech to the AMA House of Delegates, AMA president Dr. Robert Wah characterized the planned implementation of ICD-10 as analogous to the dark forces controlling the galaxy in the movie Star Wars:

“If it was a droid, ICD-10 would serve Darth Vader… For more than a decade, the AMA kept ICD-10 at bay – and we want to freeze it in carbonite!”

Dr. Wah’s attempt at humor is unfortunate because the quality and precision of our national health care data is a serious matter. In this country, we use coded data to assess quality of care, make benefit coverage decisions and to determine physician and hospital payment. The financial viability and performance assessments of hospitals and physicians are impacted by the data. Yet we continue to rely on an outdated 1970s-era coding system for reporting diagnoses and inpatient hospital procedures.

In his speech, Dr. Wah goes on to lament:

“Sucked into a jet engine? Burned by flaming water skis? Yes, there are codes for that.”

While at first glance these examples appear humorous, it is important to understand that these cause of injury codes were included in ICD-10 to meet the needs of organizations like the Department of Defense (aircraft accidents are an important issue for the military) and Worker’s Compensation (in waterski shows the burning waterski trick can lead to a worker’s comp claim). Should our national coding system ignore the needs of the Department of Defense and Worker’s Compensation?

Using cause of injury codes to imply that the coding detail in ICD-10 will be a burden to physicians is at best disingenuous because physicians are not required to report cause of injury codes, except in very limited situations such as injuries caused by medical treatment, like removing the wrong limb. Furthermore, the current ICD-9 system has similar cause of injury codes and their existence has never been a burden.

Dr. Wah continues to criticize by stating:

“We’d see 13,000 diagnosis codes balloon into 68,000 – a five-fold increase.”

Again, the inference is the increase is unnecessary and will be a burden for physicians. This is like saying the English language is a burden to use because there are 470,000 words in Webster’s unabridged English dictionary. Just as no one is expected to know rarely used words like floccinaucinihilipilification or use all 470,000 words, physicians and other providers will only use the codes relevant to their patient population (e.g., an ophthalmologist will primarily use only the eye codes).

The notion that more codes create a burden is out of touch with today’s digital world. As with almost everything else, there’s an app for that. In fact, there are more than 50 ICD-10 iPhone apps that allow a person to use word search to find an ICD-10 code instantaneously. Ranging from $1.99 to $10.99, the cost isn’t a burden (there are even a few free versions).

Dr. Wah complains about the number of codes and the detail in ICD-10 but fails to mention that much of the additional specificity in ICD-10 was at the request of medical specialty societies. Nor does he mention that there are no ICD-9 codes for many critical healthcare issues. There is no code to report and track Ebola. There are inadequate codes for tracking service-related health problems for our veterans. There are no codes to help us research sports-related concussions among young athletes. It’s hard to understand why the AMA is not demanding that this kind of information be available in our national data.

Dr. Wah goes on to state:

“We all know ICD-10 is expensive to implement. We don’t know if it will improve care.”

While there are significant costs associated with the implementation of ICD-10, the vast majority of the health care industry has already incurred those costs. In our digital world, the infrastructure for a systems change like ICD-10 has to be built and tested well in advance. These are sunk costs which will be lost if ICD-10 is not implemented. Indeed, CMS has estimated that the health care industry has already invested billions in preparation for ICD-10: “Forgoing ICD-10 translates into a loss of up to $22 billion for the U.S. health care industry” (Federal Register, 77(172), p 54689).

As to whether ICD-10 will improve care, it would seem obvious that more precise data should lead to better identification of potential quality problems and assessment of provider performance. There are multiple provisions in current law that alter Medicare payments for providers with excess patient complications. Unfortunately, the ICD-9 codes available to identify complications are woefully inadequate. If a patient experiences a complication from a graft or device, there is no way to specify the type of graft or device nor the kind of problem that occurred. How can we as a nation assess hospital outcomes, pay fairly, ensure accurate performance reports, and embrace value-based care if our coded data doesn’t provide such basic information? Doesn’t the public have a right to know this kind of information?

Our national healthcare data is broken due to the use of an archaic coding system. Given Dr. Wah’s “freeze it in carbonite” comment, it is clear that he is not really interested in a delay of ICD-10 but instead wants ICD-10 to never be implemented. It is hard to fathom why anyone would promote having our national data fail to meet the demands of 21st century health care. This is especially perplexing given that ICD-10 has been adopted by virtually every other country.

In attempting to relegate ICD-10 to the equivalent of “a galaxy far, far away,” Dr. Wah inexplicably ignores the implications for U.S. health care if we continue to use ICD-9 codes. This isn’t about waging a mythic battle (with sound bites instead of light-sabers). It’s about improving quality of care and patient safety in the here and now. It’s about ensuring fair payment, and in the case of Ebola, it’s about protecting our citizens. Yoda from Star Wars said it best: “Always in motion is the future…a little more knowledge lights our way.”

Applying Transparency to ICD-10

Jason Gottlieb

by Mark Spivey, ICD-10 Monitor

For full article, click here

“Transparency” is a term typically reserved to apply to government entities or picture windows – not ICD-10.

But Greg Adams, vice president of the consulting division of Panacea Healthcare Solutions, says it applies to that, too.

“You may have heard about price transparency since there has been a lot of publicity around this topic with a recent study by the Catalyst for Payment Reform showing that two-thirds of states received a failing grade for their healthcare price transparency laws – while another seven states squeezed out a D grade,” Adams noted, adding that only two states, Massachusetts and New Hampshire, managed an A grade.

“While the emphasis has been on price transparency,” he added, “I think of transparency in a broader perspective than just price.”

In its simplest terms, Adams explained, transparency in any market, the healthcare market included, is the ability to have sufficient information to compare the value of products.

“For healthcare this has recently been defined as quality over price,” he said. “Having this type of transparent information allows consumers to compare providers. In an economic sense, markets cannot function efficiently without transparency. If a buyer cannot distinguish the differences in price and quality between suppliers, then there cannot be an efficient market.”

As the U.S. healthcare industry amounts to something of an inefficient model, historically it has been “difficult, if not impossible” to compare hospital prices and quality, Adams added. But he also said the industry seems to be nearing a tipping points as patients become more responsible for a larger and larger portion of their healthcare bills.

“I believe transparency will happen, (and) it will happen fast. And it will be defined as price and quality – in other words, value,” Adams said. “We all agree that ICD-10 is connected to clinical documentation improvement, and clinical documentation improvement is connected to quality through the accurate coding of the medical record. And since quality is part of the value equation, remember that value equals quality/price.”

The bottom line?

“Coding in ICD-10 will result in a better reflection of the quality of care provided and improve transparency in healthcare,” Adams said.

NYP ICD-10 Project Update: December

Jason Gottlieb

As we roll into the holiday season, the ICD-10 Project Management Office would like to offer thanks to the more than 75 core project team members and hundreds of additional NYP staff, management, and leadership who tirelessly continue to contribute effort and expertise to the ICD-10 transition initiative. Effort and expertise that is readying NYP to code for those dangerous ‘holiday season’ conditions. Conditions such as being pecked by a turkey (W61.42XA). Or for those ambitious but unqualified Christmas light installers, T75.4XXA (Electrocution, initial encounter). And of course, no holiday season would be complete without the stresses of dealing with… THE IN-LAWS (z63.1).

The ICD-10 Project is a microcosm of the ongoing multidisciplinary collaboration that makes NYP the successful organization it is and is evidenced by the team’s most recent accomplishments across several of its stated milestones.

  • Operationalize a dual coding production environment.  NYP actually started coding using the ICD-10 code set more than one year prior to the October 1 implementation date. Through November, more than 5000 inpatient discharges and several hundred ambulatory surgery and emergency department visits have been coded in ICD-10. Though we can’t submit these codes to insurance companies, we are storing this information for external testing and analyzing it for potential reimbursement impacts and subsequent remediation activities.
  • Complete end-to-end claims testing with payers.  Our best evidence that the transition to ICD-10 will be smooth and seamless lies in our ability to submit test claims electronically to insurance companies and have those insurance companies acknowledge receipt and demonstrate an ability to process those claims in the form of accurate payment. To date, NYP has performed tests of varying levels of complexity and size with 7 of our largest contracted payers representing nearly 40% of the Hospital’s revenue.
  • Support hospital operations with an ICD-10 ready technology and data infrastructure.  All but one of the Hospital’s identified applications has been updated to be ICD-10 compliant. This means that the revised form and structure of ICD-10 codes can be accommodated for entry and storage and in many cases any functional processing for which the codes are used as criteria. In addition, to ensure those codes move seamlessly across different applications, approximately 10% of the affected interfaces have already been successfully tested.
  • Manage the ICD-10 impact on quality and patient safety reporting.  Through an innovative approach developed by the NYP team, 9 quality and patient safety metrics affecting value based purchasing incentives have been assessed. Two, accidental puncture and laceration and DVT/perioperative pulmonary embolism have been identified as being potentially impacted by the transition to ICD-10. The workgroup is evaluating potential mitigation strategies.

Many other activities are ongoing and progressing nicely. For a complete overview of the project status, click here to view the Project Scorecard.

Projects as complex as ICD-10 are not without their challenges and as we head into the final 300 days before October 1, 2015 efforts are underway to address these. They include:

  • Maximizing the benefit of computer assisted coding technologies
  • Further accelerating and expanding dual coding activities
  • Accelerating claims testing activities with payers
  • Continuing to identify mission critical reports for ICD-10 conversion activities.

Because ICD-10 is the dictionary that defines our daily operation, it has the potential to affect as many as 10,000 to 15,000 NYP employees in some way. We all can play a role in NYP’s readiness activities and prepare our respective departments for the transition. Some of those items include:

  • Recognizing the transition is coming and the differences between ICD-9 and ICD-10 code structures;
  • Identifying reports, documents, and forms that are using ICD-9 codes today so that they can be converted to ICD-10;
  • Thinking about how the additional specificity included in ICD-10 can help create efficiencies and improved outcomes in your operation; and
  • E-mailing questions about ICD-10 and how it may affect you and your department to ICD10Help@nyp.org.

Happy Holidays to all!

Will ICD-10 be Delayed Again?

Jason Gottlieb

by Dan Haley, VP of Government and Regulatory Affairs

See full article here.

Is the October 2015 deadline real this time? Are the feds going to punt again? They aren’t ever going to pull the trigger on ICD-10, right?

All reasonable questions, especially after the October 2014 deadline — supposedly a hard-and-fast date — was unceremoniously kicked down the road by a year.

When it comes to ICD-10, providers fall generally into two categories: Those who actually invested time and money to be ready for October 2014, and, having been burnt once badly, are leery of approaching the ICD-10 stove again. Then there are providers who feel validated that they had correctly bet the feds would blink — and may be more comfortable making that bet again next year.

The policy meteorologists uniformly predicted stormy weather. Yet a whole lot of people went outside without an umbrella and ended up enjoying a beautiful, sunny day. Why shouldn’t the same scenario play out again in 2015?

Despite all of the time I spend in the company of federal health IT policymakers, I have precious little insight to offer. The people in DC who are in charge of the transition are emphatic, both in public and behind closed doors: this time, they say with uniform certitude, the deadline is real. Count on it. Tomorrow the sun will rise in the east, this winter the New England Patriots will make the playoffs (hey, I’m in Boston), and in October 2015, the nation will switch over to ICD-10.

Considering past performance as an indicator of future action, skeptics can certainly be forgiven for their lack of faith. So how can we at athenahealth say, with a straight face, we think this thing might just be real this time? A few reasons:

  1. The 2014 delay was almost certainly political. With the nation just barely over the calamitous roll-out of healthcare.gov, there was no way the White House would implement a massive code switchover that could well have rendered a majority of the country’s providers temporarily unable to be paid for their services, just one month before the midterm elections. Unequivocal statements by everyone including Centers for Medicare & Medicaid Services (CMS) head Marilyn Tavenner notwithstanding, this year’s delay was entirely predictable. 2015, on the other hand, is not an election year. Even if providers are not appreciably better prepared for ICD-10 next year than they were in 2014, it may not matter — chaos is more politically palatable in an off year.
  2. The recent Ebola scare lends a new degree of urgency to upgrade U.S. systems to match the code set already in use in much of the world, to better enable the disease identification and tracking necessary for a global health crisis response. Nothing motivates change in Washington like an emergency.
  3. Of course, there is the Affordable Care Act. With the rolling implementation of the law, provision of and reimbursement for care is getting more complex. At some point, the continued use of a code set rolled out in the Watergate era, and long-retired in much of the modern world, becomes untenable.

Regardless of the continued uncertainty surrounding the October 2015 deadline, at athenahealth we are encouraging providers to get ready for ICD-10 and are preparing and testing on our clients behalf. Our cloud platform had our entire provider base ready well before October 2014, and will have it ready again months before October 2015, at no additional cost to those clients. And we are working hard — again — to make the transition as easy and painless as possible.

Like meteorologists, political prognosticators are often wrong, sometimes radically so. Even though we sometimes get to enjoy unexpected blue skies, eventually it pays to dress for stormy weather. DC is again confidently predicting a switch to ICD-10 on October 1, 2015, and there is no upside to bet against that happening. No matter when it does, athenahealth will be holding the umbrella for providers.

Responding to Physician Criticism of ICD-10

Jason Gottlieb

Written by

See full article here.

For those physicians who have studied ICD-10 extensively, the overall impression among them is that it is a vast improvement over ICD-9. The most common criticism, the increased number of codes, should be addressed first.

It is true that the number of diagnosis codes in ICD-10 increases by approximately a factor of five over ICD-9. Many physicians bemoan the fact that they will have to learn five times as many terms as they knew under ICD-9. Yet this simply reflects a lack of knowledge. Consider, for example, a non-traumatic subarachnoid hemorrhage. Under ICD-9, this diagnosis fell under the categorical single code for subarachnoid hemorrhage. In ICD-10-CM, there is a specific category for non-traumatic subarachnoid hemorrhage featuring 20 specific codes. Going from one to 20 codes is a big leap. Does this reflect a lot of new learning for physicians?

Hopefully not.

What the code expansion actually represents is huge advances in clinical medicine made in the 35 years since ICD-9 was drafted. Specifically, we now have technology (CT/MRI/angiography) that can identify the specific artery involved (middle cerebral, basilar, anterior communicating, etc.) as well as laterality for many of those blood vessels. It is basic, responsible practice of medicine to identify the nature of the non-traumatic subarachnoid hemorrhage, in today’s clinical world.

Cardiology is a specialty for which terminology has improved significantly. The “new” terms for acute myocardial infarctions in ICD-10-CM are STEMI and NSTEMI (terminology that, incidentally, has been used by cardiologists, internists, and others for the last couple decades).

One area of legitimate concern among cardiologists relates to specificity regarding type of heart failure (acute or chronic, systolic, diastolic, or combined). Many cardiologists historically have not made such a differentiation, but they should acknowledge that this terminology is not new under ICD-10-CM – it’s also the codeable terminology found in ICD-9.

Is there a high degree of specificity in ICD-10-CM? Absolutely. And it is perhaps nowhere better exemplified than in orthopedic diagnoses. Just as an example, there are a myriad of codes for fractures of the femur. That sounds extreme until one actually learns how ICD-10-CM works. The new coding system includes terminology that every orthopedic resident must learn: the Gustilo classification of open fractures, the Salter-Harris classification of epiphyseal fractures, as well as other essential information such as specific anatomic site, type of fracture (spiral, etc.), and of course, laterality.

For neurosurgeons and trauma surgeons, ICD-10-CM includes provisions for the documentation of attributes of head injuries such as duration of loss of consciousness for cerebral edema as well as Glascow coma scores.

A comment from an internist in Anchorage, Alaska put ICD-10-CM into sharp perspective. He said (and I agree) that ICD-10-CM is exactly what we should expect from a resident in a morning report. So should we expect any less from practicing physicians? This observation should be reassuring to most physicians. I will admit, however, that the challenge is not the same for all specialties. Generalists, whether they are trained in family medicine, internal medicine, or emergency medicine, treat patients with a broad scope of diagnoses and will require more assistance transitioning to ICD-10-CM.

I should also mention ICD-10-PCS, the procedural coding system. Here we have a far greater increase in the number of codes. The marked expansion in the number of codes in ICD-10-PCS is primarily due to the architecture of the PCS system. ICD-10-PCS codes capture information impossible to capture in ICD-9, such as specific body parts, types of operations, types of devices left in a patient, and more. While this seems like it might present a lot more work for the physician, in most instances a quality operative report will include all the necessary information for coding, particularly if physicians are educated on basic code structure. It is unnecessary and absolutely not recommended that physicians memorize any ICD-10-PCS codes.

Let me share an observation from dealing with hospitals and medical staffs from across the country. The strongest physician advocates of ICD-10 appear to be those working in academic medical centers. That is, perhaps, because specificity and accuracy of diagnoses and procedure documentation are key components of residency and fellowship training. Additionally, most academic physicians recognize the lack of utility of ICD-9 for clinical research or epidemiology. ICD-10 provides much better information for such purposes.

I will conclude with one final observation. ICD-10 presents different challenges to different constituencies. I am very sympathetic to coders. They are essentially learning a new language, and they need to learn it for all specialties, all diagnoses, and all procedures. And here is where some of the confusion may have arisen for physicians who have not as yet learned much about ICD-10. We, fortunately, do not face the same challenges. For the vast majority of physicians, we can constrain our focus to our specialty areas.

In so doing, we quickly realize that the information needed for ICD-10 generally mirrors that which is required for high-quality patient care.

ICD-10 holds true promise for improved clinical terminology

Jason Gottlieb

Written by Dr. Abhishek Jacob

See full article here

It is common knowledge that ICD-10 CM & PCS code sets will increase granularity, improve axes of classification and provide a more scientific approach to coding, opening up tremendous growth in our understanding of disease conditions and associated treatment protocols.

For the first time in 36 years, we have the opportunity to revamp the clinical terminology being used to measure effectiveness of healthcare services, refine clinical grouping and associated reimbursement methodologies and enhance capability to conduct public health surveillance.

Today’s Challenges

  1. Many provider organizations believe that because ICD-10 has been characteristically complex to implement and includes many new and potentially amusing codes (e.g. W59.22XD – “struck by turtle, subsequent encounter”), the increased quantity may not be very useful from a treatment and re-imbursement perspective. These issues significantly undermine the potential benefits ICD-10 will have on documenting and reporting clinical conditions, enhancing clinical terminologies and, most importantly, measuring the effectiveness of treatments for better disease surveillance – like the current course of action and treatment during the recent outbreak of Ebola cited later.
  2. Though a competing priority, Meaningful Use (MU) implementation has a mutual dependency and benefit to ICD-10. One of the most important drivers of meaningful usage of EMR is allowing clinical data to be effectively utilized and shared between EHR systems. To accomplish this objective of using standard clinical terminologies, ICD-10 and MU requirements must be incorporated into EHR systems concurrently. This would help achieve comprehensive system interoperability and shed light on the benefits of a national health information infrastructure. ICD-10 and MU implementation are complimentary and are required to be applied together, and therefore should not be viewed as conflicting priorities.
  3. Last, rather than being used as a counterpoint to discredit the tremendous potential benefit of ICD-10 implementation, many of the so-called irrelevant codes, such as “struck by turtle, subsequent encounter,” fall in external causes of injury chapter and are not necessarily required for reimbursement of diseases surveillance, which means their usage can be restricted on a case to case basis.

ICD-10: The Next Generation of Clinical Terminology and Coding

ICD-10 holds true promise to expedite a much needed revamp of existing clinical terminologies and coding for high value patient encounters. Below is an analysis of a simple example that compares how ICD-10 provides significant enhancement to our ability to measure healthcare services and how increased sensitivity would assist in refining existing grouping and reimbursement methodology.

With more than 650,000 procedures per year, angioplasty in one of the most commonly performed operations, contributing approximately $13 billion per year to U.S. healthcare spending. According to a study published in The Journal of the American Medical Association in 2012, almost half of the angioplasties conducted in non-emergency situations may not benefit patients. In ICD-9 CM, angioplasty is represented by only 1 code- 39.50 and since ICD-9 CM lacks the granularity, it might not be possible to relate the clinical outcomes of the procedure with the associated reimbursement.

ICD-9-CM

Angioplasty – 1 code (39.50)

ICD-10-PCS

Angioplasty – 854 codes

ICD-10 CM not only specifies the body part the procedure was conducted on but also the approach, the device used and the type of stent placed. This granularity allows for correlation between clinical outcomes and a specific type of procedure, thereby improving the overall efficacy of the treatment.

Some examples of ICD-10 granularity of Angioplasty codes include:

  • 047K04Z – Dilation of right femoral artery with drug-eluting intraluminal device, open approach
  • 047K0DZ – Dilation of right femoral artery with intraluminal device, open approach
  • 047K0ZZ – Dilation of right femoral artery, open approach
  • 047K34Z – Dilation of right femoral artery with drug-eluting intraluminal device, percutaneous approach
  • 047K3DZ – Dilation of right femoral artery with intraluminal device, percutaneous approach

The granularity that comes with ICD-10 is critically important to the future of our healthcare system. The outbreak of Ebola has allowed many analysts and experts in the field to stress how ICD-10 and improved clinical terminology intensifies the need and benefits of the new code set. ICD-10 could allow healthcare providers to measure the effectiveness of treatments for better disease surveillance and outbreak response.

ICD-9 CM has no specific code for reporting Ebola hemorrhagic fever (EHF). The closest match is 065.8 “other specified arthropod-borne hemorrhagic fever.” ICD-10 CM has a specific code, A98.4 “Ebola virus disease.” In ICD-9 CM Ebola is classified under “arthropod-borne viral diseases” whereas in ICD-10 it is classified as “arthropod-borne viral fevers and viral hemorrhagic fevers.”

There is currently no drug or vaccine available to treat Ebola and most of the treatment is based on experimental drugs. Since the outbreaks, until now, have appeared prominently in Africa, where there is a very restricted use of standard clinical terminology and modern EHR systems, little information is available about the natural reservoir host of Ebola virus.

And as we’ve witnessed, because physicians aren’t able to accurately document the causative factors, strains of virus and treatment protocols, our response to the outbreak has been restricted to a tactical stoppage of spread. ICD-9 CM does not have any codes to document Ebola accurately, and though ICD-10 CM has only one code to report Ebola, the ability to expand the categorization in ICD-10 ensures that researchers, authorities and care providers can better prepare for response, resulting in potential lives and millions of dollars saved. This is a classic example of how accurate usage of clinical terminology for disease surveillance associated with ICD-10 implementation holds true promise.

Continued use of ICD-9-CM as a medical code set standard threatens to jeopardize the ability of the U.S. healthcare industry to effectively collect and use accurate, detailed healthcare data and information for the betterment of domestic and global healthcare. Clinical terminology modernization and standardization are amongst the most important steps required to maximize the power of healthcare data and, in doing so, build a better healthcare system for the 21st century.

ICD-10 and Value Based Purchasing (VBP)

Jason Gottlieb

Written by Gregory M. Adams, FHFMA

See full article here

According to the group Catalyst for Payment Reform, of the value-based payment models in action, 53 percent of commercial payer VBPs put providers at some financial riskif they fail to contain costs or improve care.

However, on the flip side, many value-based payments still fall into the category of pay-for-performance, which offers providers only potential financial rewards and no risk. I believe that the progression of VBPs will move quickly away from this model into models that will penalize providers for poor quality.

This is already being done by the Medicare program, which is seeing to it that hospitals are slapped with big penalties that experts say are only increasing. A recent study from CipherHealth shows a mounting $1.6 billion in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and readmission penalties facing hospitals today. That’s $1.6 billion! The survey calculated that at more than 500 hospitals nationwide, the three-year at-risk amounts were $3,500 per inpatient bed.

Based on a study by the PWC Health Research Institute, the financial impact of these value-based reforms is expected to have a significant impact on low-performing hospitals. For example, a 300-bed hospital with poor quality metrics would be penalized approximately $1.3 million a year, beginning in 2015, under Centers for Medicare & Medicaid Services (CMS) value-based reforms. And this doesn’t consider the impact of reduced payments from commercial payers. In this example, if we assume that another 30 percent of the hospital’s revenue is commercial, using the same penalty relationship, the hospital would lose over $2 million a year.

Now, let’s put that number into perspective – while profitability for hospitals increased overall in 2012, there was a wide disparity in hospital performance, with over 30 percent of hospitals running at a loss. For those hospitals, even a small decrease in payments will strain resources. So, how does a hospital fix any quality issues through changes in operational practices, which will cost money, while receiving less in payments? It will not be easy, and keep in mind that any quality comparisons, at least at the federal level, are a moving target. Under the current CMS formula, not only do providers need to improve their scores, they need to improve at a faster rate than other hospitals nationally to benefit.

Now how does VBP relate to ICD-10? Well, the accuracy and completeness of coding drives many of the quality and severity-of-illness indicators that in turn determine value-based payments or penalties. And with the increased complexity of coding under ICD-10, the potential for inaccurate coding increases exponentially. On top of that is the uncertainty of how both CMS and commercial payers will change their measurement criteria for quality and value with the increased specificity of the ICD-10 codes. With all of these unknowns, one thing is clear – clinical documentation is, or should be, a top priority for every provider. The accuracy and preciseness of the coding of a patient’s record ultimately will affect VBP payments and whether reimbursement decreases, increases, or stays the same during the ICD-10 transition. Millions of dollars are hinging on your clinicians and coders, so here are two tactics to help you tackle these transitions.

Workgroup for Electronic Data Interchange (WEDI) releases latest ICD-10 readiness survey results

Jason Gottlieb

The Workgroup for Electronic Data Interchange (WEDI), the nation’s leading nonprofit authority on the use of health IT to create efficiencies in healthcare information exchange, announced the release of its findings from its August 2014 ICD-10 Industry Readiness Survey. The latest survey results are based on responses from 514 respondents, consisting of 324 providers, 87 vendors and 103 health plans.

Since 2009, WEDI has conducted nine ICD-10 readiness surveys in an effort to gain a broad perspective on the readiness status for different sections of the industry, and to gauge how quickly they are progressing towards the Oct. 1, 2015 implementation deadline. The full survey results are contained in WEDI’s September 19 letter to the Department of Health and Human Services (HHS) which can be viewed online via the WEDI website. Highlights from the latest survey findings include:

  • Vendor product development: About 40 percent of vendors indicated they are complete with product development. This is an improvement over the October 2013 survey.
  • Vendor product availability: More than 25 percent of vendors responded that their products would not be ready until 2015 or responded ‘unknown.’
  • Health plan impact assessments: Nearly 75 percent of health plans had completed their impact assessment.
  • Health plan testing: More than 50 percent of health plans have already begun external testing compared to less than 25 percent in the prior survey.
  • Provider impact assessments: About 50 percent of the providers indicated they have completed their impact assessment—essentially the same number as in the October 2013 survey.
  • Provider testing: About 35 percent of providers have begun external testing, while in the October 2013 survey about 60 percent had expected to begin by the middle of 2014.
  • External testing approach: About 60 percent of health plans expect to test with a sample of providers, while about 20 percent indicated they will test with a majority of providers.

“Based on the survey results, all industry segments appear to have made some progress since October 2013, but the lack of progress by providers, in particular smaller ones, remains a cause for concern as we move toward the compliance deadline,” said Jim Daley, WEDI chairman and ICD-10 Workgroup co-chair. “Delaying compliance efforts reduces the time available for adequate testing, increasing the chances of unanticipated impacts to production. We urge the industry to accelerate implementation efforts in order to avoid disruption on Oct. 1, 2015.”

WEDI will continue its efforts to move the industry forward and plans to continue its surveys to gauge industry readiness. WEDI has conducted several ICD-10 forums—the most recent of which was in July 2014—and plans to hold additional events in 2015, as well as continue to provide educational opportunities and produce work products to assist the industry in preparing for ICD-10 implementation. More information on WEDI events and ICD-10 work products are available on the WEDI website.

- See more at: http://www.wedi.org/news/press-releases/2014/09/25/Results-from-WEDI-ICD-10-Industry-Readiness-Survey-Released#sthash.y5QeiaRr.IPe8lLJa.dpuf