Saturday, November 19, 2011

ICD-10 precursor delayed: Will ICD-10 be next?

The Centers for Medicare and Medicaid Services (CMS) announced that it will delay enforcement of its rule that all covered entities under the Health Insurance Portability and Accountability Act (HIPAA) upgrade from the 4010 standard for claims transactions to the 5010 standard.  CMS has said that it will not enforce the January 1, 2012 deadline, delaying such action now until March 31, 2012.

Now, for someone unfamiliar with the details of CMS, HIPAA, and how health insurance claims in the United States are handled, the preceding paragraph will make no sense.  The rest of this paragraph is a primer.  Those who understood the previous paragraph may skip to the next one.  In the United States, to receive reimbursement for their services, healthcare providers such as hospitals and physicians must submit insurance claims on behalf of the insured, who waives her right to receive payment on the claim (and so the doctor/hospital receives payment of the claim directly without going through the insured party).  Because nearly everyone over the age of 65 in the United States is insured by the federal government through CMS, and because nearly every doctor and hospital in the United States cares for patients ensured by CMS, CMS has broad leverage to force doctors and hospitals to change how they care for all patients by dictating how they care for CMS patients.  And hence, just about every doctor and hospital in the United States is a "covered entity" under the HIPAA law.  CMS has the authority under HIPAA to dictate how covered entities submit their insurance claims to CMS.  It is a general rule that private insurance companies follow CMS, so they require providers to follow HIPAA claims transactions standards as well.

Now, the primary, HIPAA-mandated insurance claims standards are a family of standards that go under the broad heading of '4010'.  CMS has mandated that covered entities upgrade to the 5010 family, in large part because it is necessary to implement 5010 before switching to ICD-10.

The delay to 5010 therefore puts the October 1, 2013 deadline for the ICD-10 switch at risk.  And because October 1 represents the first day of the federal fiscal year, it will be difficult to manage anything other than a delay that is an integral number of years (October 1, 2014, 2015, etc.) in the switch to ICD-10.

This delay in the 5010 deadline and the AMA's decision to fight the switch to ICD-10 are just manifestations of the unrealistic expectations, and the policies based on them, that this blog has pointed out for three years. 

Yes, stop the switch.  Let's have an open and honest conversation about what our next-generation information infrastructure should be, and what diagnosis coding system can best support it.

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