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After Two Decades, A Few Simple Questions

The healthcare industry has endured more than 20 years of research, hearings, testimony, proposed rules, comment periods, final rules, and three ICD-10 delays. Nearly $30 billion in costs have been incurred to plan, train, convert systems, test, and prepare for ICD-10. Countless hours, months, and years have been devoted to the ICD-10 transition by hospitals, physician practices, commercial payers, federal and state agencies, and vendors. Thousands of students have been trained in ICD-10 and are ready to enter the workforce.

Yet, the Heritage Foundation proposes that we start over?

In a recent report, Heritage called on Congress to “delink” ICD disease classification from reimbursement policy because, they maintain, the use of ICD has made the billing process overly burdensome. The report goes on to suggest that providers have the choice of using the current ICD-9 system or adopting the new ICD-10 system while Congress develops a “more appropriate” diagnosis coding system for reimbursement.

The Heritage Foundation report is the latest attempt by special interest groups to block implementation of ICD-10. It’s the same tired arguments we’ve heard for the past 20 years.  The proposals put forth in the report would not only result in the loss of enormous investments that have already been made, but would require extraordinary additional investments. On behalf of the majority of U.S. healthcare industry stakeholders represented by the Coalition for ICD-10, we must ask:

How much longer must we wait for better measures and higher-quality information needed to improve patient care? To manage costs? To ensure fair payment?

How many more millions of dollars will we be asked to divert to the creation and implementation of a “more appropriate” coding system, which could be used for purchasing new patient care equipment, investing in clinical research, and hiring additional caregiver resources?

A “more appropriate” coding system

What would constitute a more appropriate diagnosis coding system? Given the growing demands for better, more precise healthcare data, why would anyone think that a new coding system would be any different than ICD-10?

What would be the point of developing a new diagnosis coding system? CMS’ latest end-to-end testing results showed only 2% were rejected due to ICD-10-related errors – less than the rejection rate following the annual ICD-9-CM code changes.  So clearly providers are easily able to report ICD-10 codes.  And virtually all of physicians’ payment is based on the AMA’s CPT codes. The only substantive impact that diagnosis codes have on physician reimbursement is in the areas of coverage, medical necessity and quality measures. So is the Heritage Foundation calling for a new system for coverage, medical necessity and quality measures?

And how would developing another diagnosis coding system decrease costs, burden, or complexity? After all, it would require that providers use two coding systems instead of one—ICD for research purposes to fulfill international disease reporting requirements, and a different system for capturing diagnostic information for reimbursement purposes. Not only would it be costly to maintain two different diagnosis coding systems, but it would also be costly and burdensome for providers to report two different sets of codes.

The Heritage Foundation report also fails to mention that ICD is not the only classification system used for physician reimbursement. Physicians are primarily paid based on CPT codes, many of which are very specific. There are nearly 10,000 CPT codes and 30 CPT modifiers. Up to four CPT modifiers can be reported with each CPT code resulting in essentially a limitless number of possible unique CPT code and modifier combinations. Why is it that CPT codes are not viewed as overly burdensome, but ICD-10 codes are?

Allowing providers the choice of using ICD-9 or ICD-10

Calling for a dual coding system, which would give providers the choice of using ICD-9 or ICD-10, is the equivalent of mandating another delay in ICD-10 implementation. The Coalition maintains that dual coding would be unworkable, costly and confusing. A dual coding system is not a simple solution, but is fraught with difficulties that have the potential to undermine the data infrastructure of the healthcare industry.

Dual coding would require extremely complex and costly changes to major payment, clearinghouse and provider systems. Even more troubling, the communication of health information between providers would be compromised (is patient information based on ICD-9 codes or ICD-10 codes?), adversely impacting the quality of care and increasing the potential for patient harm.

Perception vs. reality: Physician support of ICD-10

Despite the Heritage Foundation’s argument that ICD-10 would be a hardship for physicians, and general perceptions that all physicians oppose the transition to ICD-10, there is a long history of extensive involvement and support by physician groups throughout ICD-10-CM development. In fact, much of the additional clinical detail in ICD-10 was recommended by physician groups. In recent months, there have been strong physician voices in support of ICD-10.

For the Heritage Foundation and others, however, who are still questioning ICD-10 adoption, it comes down to a few simple questions:

  • For taxpayers: is it reasonable to expect physicians to provide precise information about the clinical conditions of their Medicare patients when you and other taxpayers are paying for that care? At a time when we are trying to reduce healthcare spending, should the federal government and the healthcare industry spend additional billions of dollars to recreate and re-implement a code set?
  • For patients: Are you comfortable with having inadequate information in your medical record? Isn’t failure to document whether your broken arm is the right arm or left arm a quality of care problem?
  • For physicians: Are you willing to have your performance judged and your quality scores based on 30-year-old codes that no longer reflect modern medical practice?
  • For hospital and health system executives: Are you comfortable using ambiguous and outdated coded data to develop your organization’s strategic plan, determine risk-sharing agreements, and report outcomes?
  • For payers: Do you trust using ambiguous and outdated coded data to quantify risk, analyze managed care contracts, and determine payment?

Hospitals, health plans, providers, researchers, coders, federal agencies, state agencies, vendors, device manufacturers, and more are overwhelmingly ready and have invested tens of billions of dollars to be ready. We must end two decades of delay tactics. It is time to move forward with ICD-10.

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