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.

American Medical Association: STOP THE SWITCH

Well, for sure this post is well behind the news.   The American Medical Association (AMA) House of Delegates on Tuesday voted to "to work vigorously to stop implementation" of ICD-10.

In their own words:

The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care," said Peter W. Carmel, M.D., AMA president. At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records into their practices. We will continue working to help physicians keep their focus where it should be – on their patients.

Naturally, the next question is what will the AMA will do to derail the ICD-10 train? Well, apparently it is still too soon to tell, but it is up to the AMA Board of Trustees to implement House of Delegates resolutions, in general.   Per the chair of the Board, Dr. Robert Wah, limited resources also constrain what the AMA will be able to do to fight the switch.

The AMA is certain to endure harsh criticism for its stance. Already, some are already reacting to the AMA's decision by repeating the myths that (1) ICD-10 is advanced, (2) it will improve care for patients, (3) it will improve information management in support of #2, and (4) the U.S. is backwards because other nations have implemented ICD-10. We have shown on this blog that all these assertions are untrue.

On the contrary, the AMA is to be applauded for its courageous stance against ICD-10.

Thus, we offer to the AMA, as a modest resource, the documentation on this blog, over a multiple-year period, of the many reasons and truths about the switch, and why it will certainly not afford the benefits its proponents claim.

Latest call for ICD-10 switch repeats the myths

Dr. Wendy Wittington, Chief Medical Information Office for Dallas-based Anthelio Healthcare Solutions, repeats several ICD-10 myths in her advocacy for the ICD-10 switch:

Myth #1: "...the switch is truly necessary"

We don't have to switch to ICD-10-CM. As we previously discussed here, there is an alternative approach, that is superior to ICD-10-CM.

Myth #2: ICD-10 is more modern

ICD-10 is still based on the same, antiquated, classification architecture as ICD-9-CM (see here, here, here, here, and here). So although it may reflect how medicine has evolved, it does not reflect informatics best practices. ICD-10-CM's underlying information architecture remains in the 1970s with ICD-9-CM medical terminology. The government is developing ICD-10-CM using a word processor!

Myth #3: ICD-10-CM will accurately translate what physicians do to payers.

Doctors don't recognize 318 kinds of diabetes mellitus (see here and here). Doctors don't use the terms "not otherwise specified" and "not elsewhere classified". Doctors don't speak in classifications, they speak in medical terminology. Doctors don't combine multiple patient characteristics into new diagnoses.

Myth #4: ICD-10-CM is necessary for evidence based medicine and comparative-effectiveness research.

As long as it's a classification and not a nomenclature, it will not be sufficient.

Myth #5: Silly codes do not get in the way.

See here for what a "silly code" is. They increase the cost, difficulty, and complexity of switching. Only necessary codes should be present. They will also inflate the number of search results a physician must process in an electronic medical record when looking for codes. For example, a search for "diabetes mellitus" will return 318 results!

Myth #6: Other countries have switched, therefore we're an embarrasment

Following the pack is not always a wise strategy. For many reasons listed on this blog, switching to something other than ICD-10-CM would be leading, not following. And certainly not embarrassing.

Myth #7: "...a lot of hospitals and healthcare providers have ignored it or put it on the backburner because they are too busy with meaningful use requirements"

Whoops! That one's not a myth. Meeting meaningful use requirements is probably a better expenditure of resources, and hospitals and physicians know it and appear to be acting accordingly.

Nearly Half of Leading Healthcare Organizations Are Not Yet Switching to ICD-10-CM

A report by HealthLeaders Media finds that nearly half of healthcare leaders have not yet even begun to prepare for the ICD-10-CM switch. Overwhelmed with competing priorities, hospitals and health plans have not started on ICD-10-CM despite a misguided belief that it will help with their quality improvement efforts (72% of respondents) and a real belief that it will negatively impact revenue for years to come (46% of respondents).

Healthcare reform and the electronic health record are higher priorities. Let's turn off the switch.

ICD-10-CM Prerequisite at Risk

A Medical Management Group Association (MGMA) survey finds that just over 45% of physicians have not begun the process to upgrade to a standard that is a prerequisite for the ICD-10-CM switch. The ICD-10-CM switch requires that doctors and health plans upgrade from a standard called '4010' to its successor, 5010.

The reason: 4010 arbitrarily limited the number of characters for diagnosis codes to the maximum contained in ICD-9-CM: 5. Now, ICD-10-CM has diagnosis codes that stretch to as many as 7 characters. So, before the U.S. can start using ICD-10-CM codes for payment and reimbursement purposes, it must first upgrade the standards for submitting insurance claims.

To be sure, 5010 has other changes intended to improve the standard as well. But also to be sure, ICD-10-CM is a non-starter without it.

So, now comes news that physicians are struggling with the prerequisite to ICD-10-CM, let alone ICD-10-CM itself.

The survey results also mention that the cost of the 5010 upgrade is $16,000 per physician. With approximately 660,000 physicians in the United States today, the cost of the 5010 upgrade is $10.56 billion.

However, the final rule (warning: PDF) that mandated the 5010 upgrade states that "... the new estimate of total cost for physicians and other providers segment to implement Version 5010 is between $544 million to $1,088 million."

Too low by a factor of 9.7!

And this cost dwarfs the rosy estimates of benefit: the final 5010 rule states that "...the new estimate for physician savings due to better standards is $1,392 million and operational savings due to increase in the use of auxiliary claim transactions are $4,443 million".

So the cost already is dwarfing the best-case scenario for benefit by a factor of two.

Given that similar problems exist already with the estimates of cost and benefit of ICD-10-CM, we could save countless healthcare dollars by aborting the switch. Now!

Hospitals: ICD-10 Switch Means the EHR Must Wait

The American Hospital Association sent a letter (PDF) to the Healthcare Information Technology (HIT) Policy Committee urging a delay in implementing stage 2 of Meaningful Use criteria for electronic medical records (EMRs), in large part because hospitals are otherwise busy in switching to ICD-10-CM.

Both ICD-10-CM and EMR adoption are unfunded mandates of the federal government, although there are incentives for EMR adoption (non-adoption will eventually result in penalties that come in the form of reduced reimbursements per service). To qualify for incentives for EMR adoption, hospitals must demonstrate "meaningful use", and the federal government has set criteria for it. However, the criteria will become more stringent over time. Currently hospitals must meet "Stage 1" criteria.

The letter is about when "Stage 2" meaningful-use criteria should go into effect. Hospitals are saying that the government should delay stage 2 criteria, because the burden of switching to ICD-10-CM is too high.

As we reported here, hospitals previously asked the government to back off on meaningful use because of the switch to ICD-10-CM.

Of course, we think the EMR is more important, and that ICD-10-CM should take the back seat. Nevertheless, it illustrates one significant effect of the ICD-10-CM switch: delayed adoption of EMRs.

ICD-10 or Meaningful Use? Between a rock and a hard place.

The HIT Policy Steering Committee is debating whether delaying stage 2 of meaningful use would allow healthcare providers more time and resources to negotiate succesfully the switch to ICD-10 (or more precisely, ICD-10-CM and ICD-10-PCS).

The conflict between electronic medical record (EMR) adoption and the switch to ICD-10-CM first surfaced almost immediately after passage of the HITECH Act that incentivizes EMR adoptoin, and is highlighted by a letter from the American Hospital Association and a letter from numerous doctors' organizations.

Despite our prediction that the ICD-10-CM switch would pull resources from meeting MU, it turns out that meeting MU is taking resources from the ICD-10-CM switch.

Now, the HIT Policy Steering Committee is starting to recognize that resource-constrained healthcare providers will have severe difficulties doing both. However, it should have realized this problem much sooner since they certainly were privy to the letters sent above, dated in June, 2009. Almost two years ago!

Now they propose to delay MU "stage 2" criteria, to allow resource-constrained providers to meet the ICD-10-CM mandate.

Why not propose instead that the switch to ICD-10-CM be postponed or even canceled?

Granted, they can only control directly the timing of stage 2 MU, but surely the members of the Steering Committee have some influence with decision makers in Health and Human Services?