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 Yet we continue to rely on an outdated 1970s-era coding system for reporting diagnoses and inpatient hospital procedures.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!

ICD-10 Readiness Spotlight: Report Conversion

Rachel Tornheim

At NewYork-Presbyterian Hospital, employees across the organization use reports for a wide variety of purposes.  Whether we’re looking at operational metrics like length of stay and discharges, quality indicators like readmissions and infection rates, or financial measures related to billing and payment, it’s important that our reports be accurate and up to date so that we can make informed decisions.  Because many of the reports we rely on to run our departments, practices, and units contain ICD-9 codes, the upcoming transition to ICD-10 means that we need to update our reports to reflect the new code set.

The ICD-10 IT workgroup, headed by Ken Thibault, has been leading the effort to ensure that all necessary reports are converted to ICD-10.  The group has already created an inventory of about 150 reports that use ICD-9 codes, and has begun the process of determining which ones need to be updated, collecting the relevant ICD-9 codes, and converting those ICD-9 codes to ICD-10 codes.  Once the ICD-9 codes are mapped to ICD-10 codes, the mapping is sent to the report’s business owner for approval, at which point IT will make the necessary updates so that the report will populate properly once we transition to ICD-10.

If you are a business owner of reports, you should be hearing from the ICD-10 team in the next month or two so that we can work with you on converting your reports.  If there are reports that you use that you want to make sure are on the inventory, please reach out to the IT team that manages the system in questions.  We look forward to partnering with you to ensure that your reporting needs continue to be met post October 1st, 2015.

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.