Switch glitches starting already

With just under a month to go till the switch, problems are already becoming evident.

First, a study shows that over half of healthcare organizations are not ready for the switch.  Two-thirds of respondents were small physician practices with 1-10 doctors.  Worse, the report (warning: PDF) notes that 94% of respondents are concerned that the switch will increase their claims denial rate, meaning they will suffer cash flow issues as a result.

Second, the Medicaid programs of four states have announced that they will not be switching on October 1st, the date that healthcare provider organizations are required to switch.  Instead, they'll take incoming ICD-10 codes and convert them back to ICD-9, an approach that experts note is likely to cause numerous issues with accurate and timely payments.

The states involved are not all small ones with few providers, either.  They are California (most populous US state), Louisiana, Maryland, and Montana.

Worse still, some commercial health insurance companies might be doing the same thing.  But if they are, they have not made that information public, which is even more concerning.

We fully anticipate many more, and many worse, glitches as the switch date approaches and passes.  We'll note them here, unless of course, the nation finally wakes up and stops the switch.

Docs, feds compromise on switch

The American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) announced a compromise on the switch to ICD-10-CM.  The AMA, for its part, will begin investing time and effort into helping physicians get ready for the switch.  CMS, in response, will approve claims encoded with ICD-10-CM even if the specific ICD-10-CM code used wouldn't normally meet "specificity" criteria for payment.  That means a doctor would receive payment for coding an injury with a code that does not indicate the laterality of the injury, for example.

Each side, however, remains firm on its stance on whether the switch should happen at all.  The AMA and many of its state-level affiliates (especially California, New York, Texas, and Pennsylvania) remain staunchly opposed to the switch.  CMS remains insistent that the switch should and will occur.  Of course, Congress overrode that insistence last year, postponing the switch by an additional year.  This year, legislative relief from the switch seems unlikely, although we should all continue to press for it.  Stop the switch!

More doctors organizations oppose the switch

The state medical societies of the four largest states in the country--California, Texas, Florida, and New York--have announced new opposition to the switch to ICD-10-CM.  In their letter (warning: PDF) to the Centers for Medicare and Medicaid Services (CMS), the four societies state ...mandatory implementation of the ICD-10-CM coding system is a looming disaster.  They note that simpler transitions to the HIPAA 5010 standard (a pre-requisite to ICD-10-CM) and the National Provider Identifier both had ...voluminous technical problems...

They end by saying: We remain steadfast in our belief that the ICD-10 coding system offers no real advantages to physicians and our patients — and certainly no advantages to justify the time and expense the entire health care system has invested in this transition.  As we have documented here, they are correct.  We should stop the switch.

Doctors and patients are ICD-10 losers

In a previous post, we identified the entities that stand to benefit from the switch to ICD-10-CM, namely companies that sell software to the healthcare industry.  Through forced upgrades to accommodate ICD-10-CM and new products to help healthcare providers negotiate the switch, they are benefitting to the tune of billions of dollars.

As noted by us, the Department of Veterans Affairs alone is spending $211 million on software and related services to help them with the switch.  State governments are similarly outlaying hundreds of millions of dollars to upgrade the systems that manage their Medicaid programs (note: another loser in the switch is the taxpayer).  And of course doctors and hospitals have to buy new versions of their billing/administrative and EHR systems.

Recent news reminds us, however, that among the losers are patients and doctors.  So if you are a recipient of healthcare, then you will lose in the switch to ICD-10-CM.

The main impact?  Doctors spending more time (than they do now) with medical records coders to ensure they get the correct code, so your insurance company will pay your doctor for your care.  That means the doctor spending less time with you.

Given the 15 minute rush appointments you have today, that sounds terrible.  We should stop the switch!

One, last, desperate hope to stop the switch

Representative Ted Poe (Texas, 2nd District) introduced H.R. 2126, the Cutting Costly Codes Act of 2015.  The official summary of the bill is as follows:

This bill prohibits the Department of Health and Human Services from implementing, administering, or enforcing regulations that would replace ICD-9 (International Classification of Diseases) with ICD-10 as a code set for financial and administrative transactions involving the electronic exchange of health information. ICD is a system of diagnostic codes for classifying diseases.

This bill is very similar to the Cutting Costly Codes Act of 2013 that Mr. Poe and former Senator Tom Coburn (OK) introduced, but never advanced in Congress.

Despite the merit of both bills, the factions that stand to benefit from ICD-10-CM (including medical records coders, information technology companies, and consultants) are fiercely lobbying against it and in favor of the switch.  Two major factions that ought to know better (hospitals and health plans) are paying lip service to the switch.

The only faction appropriately lobbying against the switch is doctors.  Dr. Steven Stack, President of the American Medical Association, threw the Association's support behind Poe's bill.

The conventional wisdom is that the bill is a long shot.  Having already given the AMA a long-wished-for permanent solution to the Medicare Sustainable Growth Rate (SGR) formula, Congress is not likely to wade into potentially contentious waters on doctors' behalf again this year.

Nevertheless, it is the right thing to do.  Congress, please stop the switch!

Study shows switch will create chaos in measuring patient safety

According to a study published in the January 2015 issue of the Journal of the American Medical Informatics Association, the switch to ICD-10-CM will result in ...substantial hospital safety reporting errors... In other words, the metrics hospitals use to report their performance on patient safety will be so distorted by the switch, valid pre- and post-switch comparisons will result in either (1) underreporting safety, leading patients to unnecessarily doubt the safety of a given hospital or (2) overreporting safety, leading patients to place false confidence in their hospitals.

The reason is that the national system for reporting safety, the so-called Patient Safety Indicators (PSIs) created by the Agency for Healthcare Research and Quality, rely on diagnosis codes for their calculation.  The switch to ICD-10-CM changes the meaning of the calculations, resulting in different PSI values based solely on whether ICD-9-CM or ICD-10-CM is used to compute them.

The study found that of 23 PSIs calculated using ICD-9-CM, 5 PSIs had no mapping to ICD-10-CM, 15 PSIs had 'convoluted' mappings to ICD-10-CM, and only 3 had straightforward mappings to ICD-10-CM.  A 'convoluted' mapping means that the ICD-9-CM code has no equivalent in ICD-10-CM, nor is it a more specific or more general code than the ICD-10-CM code(s) to which it maps.  That is, there is no ICD-10-CM that stands in a parent child relationship with it, or vice versa.

The authors estimated the impact of under- and over-reporting of the 15 convoluted PSIs.  They found a range of 100% underreporting of patient safety to 18% overreporting.

The switch to ICD-10-CM will create chaos for patients trying understand how safe an environment a given hospital offers.  We should not switch.

Disingenuous study underestimates costs of switch to physicians

A recent study published in the Journal of the Healthcare Information Management Association (JAHIMA) estimates the cost of the switch to ICD-10 at $8,167 per physician practice.  Per the study's authors: The ICD-10 expenditures reported in this survey and the two other recent studies are dramatically lower than the $22,560- $105,506 estimate for a small practice in an earlier study commissioned by the American Medical Association (AMA).

However, the JAHIMA study is not comparable to the Nachimson Advisor's study (warning: PDF) they cite, commissioned by the AMA.  The Nachimson Advisor's study did estimate a range of costs from $22,560 to $105,506 per practice.

However, the JAHIMA study did account for all the categories of costs that the Nachimson study did.  Both studies accounted for costs prior to the switch: manuals, ICD-10 documentation, software upgrades, training of physicians and office staff, and so on.

The JAHIMA study did not account for costs predicted to occur after the switch.  These costs include increased documentation costs and cash flow disruption.  Nachimson estimates these costs at $63,500 for a small practice, which far outweigh and dominate the pre-switch costs listed above.

Because the JAHIMA study ignored these costs, it is not comparable to Nachimson nor the true cost of the switch.

The cost of the switch will indeed outweigh its benefits.  Let's stop the switch!

House committee hearing on ICD-10 stacked with proponents of the switch

The United States House of Representatives Energy and Commerce Committee's Subcommittee on Health held a hearing on February 11, 2015 about the switch to ICD-10-CM.  However, the lawmakers on the Subcommittee stacked the deck in favor of the switch: six out of seven individuals spoke in favor of it.

Because the procedure for such testimony involves witnesses submitting a written version of what they will say in person ahead of time, these lawmakers knew the panel was egregiously unbalanced.  Therefore, this Subcommittee had already made up its mind, and the hearing was merely for show, to bolster a predetermined course of action.

Of course, that's how politics works in Washington D.C., so it comes as no surprise.  However, this approach to legislation is exactly why the public has no faith in Congress, and why Congress has the lowest approval rating of any part of the U.S. government.

The token dissenter made similar arguments to what we have put forth here: there is absolutely no need for over 200 codes for diabetes mellitus.  Actually, it's closer to 300.

At least three of the other panelists stand to benefit financially from the switch.  Rich Averill is from 3M Health Information Systems, which creates software to help organizations code with ICD.  A forced upgrade of all their customers to software that accommodates ICD-10-CM will certainly help 3M's bottom line.

Sue Bowman is from the American Health Information Management Association (AHIMA).  This organization represents individuals who code medical records with ICD for billing purposes.  AHIMA creates and sells training materials and courses to its members, so it certainly will see better financials as all its members sign up.

Lastly, Kristi Matus is the chief financial and administrative officer for athenahealth, a healthcare information technology company that sells software and services to physician practices.  Again, the forced upgrades to versions of their software that support ICD-10-CM will boost revenue significantly.

Well, so much for an objective review of the wisdom of the switch, and the possibility of taking wiser and more fiscally responsible courses of action.

Cost of delay nearly three times the cost of the switch?

The Centers for Medicare and Medicaid Services estimates (warning: PDF) that delaying the switch to ICD-10 will cost as much $6.85 billion.  However, its original maximum estimate (see page 3361, warning: PDF) for the entire switch itself was $2.3 billion.

So we're supposed to believe that a one-year delay will quadruple the cost of the switch?  When CMS wants to switch to ICD-10, it's a mere $2.3 billion, but when CMS gets mad about a Congressionally mandated delay, suddenly the delay all by itself costs $6.85 billion?

CMS estimates low when it wants to do something, and high when it does not want to do something. How petty.

President signs bill delaying switch, now it's the law

President Obama signed H.R. 4302 into law on April 1.  Thus the switch to ICD-10 is officially delayed to October 1, 2015.

Bill delaying switch passes Senate, now goes to President

Today the Senate passed without change a bill that delays the switch to ICD-10 by one year, to October 1, 2015.  It's looking better and better for at least one year of relief from the switch.

Senate to vote on bill that delays the switch

After the House of Representatives approved H.R. 4302 which delays the switch to ICD-10 for one year, to Oct 1, 2015, the Senate is set to vote on the bill on Monday 3/31 at 5:30 pm.

The specific language says: The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets...

A delay would be good.  Canceling the switch altogether would be better.

House bill would delay the switch

A recently introduced bill in the U.S. House of Representatives would delay the switch to ICD-10 until October 1, 2015 (instead of the currently mandated October 1, 2014).  Section 212 of the bill states “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard”.

This language is part of a larger bill that would adjust how Medicare pays doctors, something that Congress has passed every year since 1997.  The bill is expected to pass easily in both the House and Senate and go to the President for signature.

There could be relief from the switch, albeit temporary.

Community and critical access hospitals are likely ICD-10 losers

A recent analysis suggests that your local, community hospital is an "ICD-10 loser".  Fitch Ratings released a report that concludes that expected payment delays with the switch will overwhelm smaller hospitals with minimal cash reserves with which to weather such delays.

Many rural, community hospitals are critical access hospitals.  A critical access hospital is a hospital that is 35 miles or more from the nearest, other hospital and that has been certified by Medicare to receive full-cost reimbursement.  The rationale for improving the financial condition of these hospitals is the recognition of the essential role they play in delivering health care to rural populations.  These hospitals are typically small hospitals with fewer than 50 beds.

Yet, the switch to ICD-10 stands to overwhelm many of them.  Your local, community hospital (which for many of you is a critical access hospital) cannot afford the switch.  Let's stop the switch!

Study: Information loss will occur as a result of the switch to ICD-10

Researchers at the University of Illinois Chicago (UIC) have found that the switch to ICD-10 will result in information loss, which they deem will be significant.

This scientific result blows up the myth that the switch to ICD-10 will uniformly result in better and more information because of an increase in diagnostic precision (which is called "specificity" by proponents of the switch).

The researchers studied hematology and oncology ICD codes, which proponents of the switch have identified as the specialty that will be least affected by the switch.  The information loss affected 8% of total Medicaid codes and 1% of University of Illinois Cancer Center (UICC) codes, affected 2.9% of all Medicaid claims and 5.3% of UICC billing charges.

Although these numbers are seemingly small, according to the researchers, this level of information loss has the potential to "evaporate" the operating margin of a hematology/oncology practice.

So the medical specialty least affected by the switch could see its operating margins evaporate overnight from September 30 to October 1, 2014?

We should not switch to ICD-10.

Evidence that using upper-case 'O' and lower-case 'l' in ICD-10-CM codes is a big mistake

In a study of the accuracy of ICD-10-CM coding, a key "lesson learned" is that:  Coders often confused the number "0" (zero) with the letter "0", and the number "1" (one) with the letter "l".

This "lesson learned" should have been fully expected.  Dr. Vergil Slee and colleagues knew this problem would occur over 13 years ago in their book The Endangered Medical Record.

ICD-10-CM is a boondoggle.  We should not switch.

Oklahoma Senator files bill to stop the switch

Sen. Tom Coburn (Oklahoma) has introduced in the U.S. Senate a version of the Cutting Costly Codes Act of 2013.  This bill would block HHS from implementing the ICD-10-CM on October 1, 2014.  This action follows the filing of a similar bill in the U.S. House by a Texas congressman. 

Many of Dr. Coburn's physician colleagues in the U.S. Senate have signed on as co-sponsors of the bill.

They are correct. We should stop the switch.

Texas congressman introduces bill to stop the Switch

Texas Congressman Ted Poe has introduced the "Cutting Costly Codes Act of 2013" (HR 1701), which would put a halt to the switch to ICD-10-CM.  It is a good idea, and merits passage and signature by the President.

Doctors' organizations aligned against the switch

Led by the American Medical Association, 82 doctors' organizations have written a letter (PDF) to the Secretary of Health and Human Services opposing the switch to ICD-10-CM.  The letter was signed by 42 state medical societies and 40 specialty-specific medical societies, including the largest states (California, Texas, Florida) and most prestigious specialty societies (American College of Cardiology, American Academy of Ophthalmology, and the American Academy of Family Physicians).

The reason physicians oppose the switch is that it provides no direct benefit to patient care and the switch is only one of many regulatory burdens recently imposed by the federal government and physicians are having trouble managing them all at once.  ICD-10 is an administrative code set that supports payment for health care: it is on the "back end" and thus does not impact patient care at all, let alone favorably.  The burden of the switch is thus a net negative in doctors caring for patients, because it is costly and distracting.  The other regulatory burdens the letter calls out are (1) implementation of electronic health records to meet "meaningful use" criteria, (2) electronic prescribing, and (3) mandatory participation in the Physician Quality Reporting System (PQRS) and value-based modifier programs.

Physicians are correct.  The cost of the switch outweighs its benefits and it ought to be halted.

Ill-formed ICD-10-CM codes causing coding problems, as predicted nearly 13 years ago

Dr. Vergil Slee and his co-authors predicted in their 2000 book The Endangered Medical Record that the use of capital 'I' and lower-case 'o' in ICD-10-CM codes would cause confusion (with the numeral '1' and the numeral '0', respectively).

That prediction has come true.  Annie Boynton, director of provider regulatory compliance (ICD-10) communication, adoption and training for UnitedHealth Group, says that problems such as distinguishing between the letter “o” and the number zero and “1” and “I” result in incorrect and partial coding.

That and other technical issues with ICD-10-CM make it an antiquated system to which we should not switch!