BY DANIEL B. SHULKIN: There is reasonable concern among many healthcare professionals that the transition from International Classification of Disease Manuel Volume 9 (ICD-9) to International Classification of Disease Manuel Volume 10 (ICD-10) will create delays in hospital and physician reimbursement. After all, the number of medical procedural codes in the tenth volume is five times more than those that currently exist in the ninth volume. (68,000 alphanumeric codes in ICD-10 compared to 13,000 numeric codes in ICD-9). (1), This simply means that providers will have to document patient care plans that are more specific and detailed. Almost 80% of current clinicians have not yet begun to prepare for this transition. (2) If providers fail to document correctly, this could lead to providers either not reimbursed for services rendered or reimbursed at rates far lower than they should be. In a hospital supply chain, hospitals who are ill prepared to use ICD-10 codes will not be paid appropriately, be unable to invest the money back into supply orders thus creating a shortage of supplies and diverge patients from receiving the necessary medical care.
Since, it is so essential to train clinicians in ICD-10 to create a smooth transition, it is first important to understand why ICD codes exist and why ICD-10 is logical and necessary for the United States to adopt now. ICD codes provide exemplary clinical care. The World Health Organization endorses ICD coding to standardize a universal set of diagnostic codes to define disease management and health status across the globe. The current global edition, volume 10, was first endorsed in 1990 but came into effect around 1994. These codes help researchers, clinicians, and policy makers understand health status both domestically and internationally. For example, an illness in California could be linked to a similar outbreak in Ghana. In order to plan for and implement population health strategies, it is essential to have a universal set of codes. The United States lags far behind other advanced developed nations in adopting the latest ICD codes (3). Volume 11 is currently in the works with an estimated 2017 release date.
ICD-10 is a logical next step with the implementation of the Affordable Care Act. In order to understand the context of the transition of the ICD-10 system, we must review further facts. Since the Affordable Care Act’s (ACA) landmark passage in 2010, health care reform has created considerable changes for payers, providers, employers, and patients alike. Americans have begun to sign up for insurance as a result of the individual mandate, children can stay on their parent’s health insurance plan until age 26, and the Center for Medicare and Medicaid Services has begun to implement numerous variations leading to payment reforms. Since the ACA became a law, there have been concerns by both consumers and care providers. For many consumers, the idea of moral hazard takes effect since those who are healthier do not want to buy insurance through the exchanges partly because of the broken healthcare system, which increases wait times and has high costs of unnecessary tests and drugs that are not covered by insurance. Clinicians, on the other hand, are more worried over the decreased reimbursement rates in a fee for service system while seeing more patients. The increase and/or mandate of ICD-10 training for care providers could help alleviate many clinicians’ fears of increased workload for less compensation. This will simply help patients create a specific health care plan tailored to their needs and allow physicians to seek higher reimbursement rates for the services provided to patients. In all, some of the ACA such as the increase of open enrollment participants have been challenging to implement. Others, such as the reform of hospital payments for patients readmitted within thirty days of discharge have led to significant structural changes in the healthcare ecosystems.
With all that is happening with healthcare reform, why are we planning to transition to ICD-10 next year? Another major change is just too much for our system to bear. What is the urgency for implementation of ICD-10 coding and will our system be able to tolerate even more change? Canada and Australia implemented ICD-10 codes towards the end of the twentieth century and have found the change necessary and eventually rewarding. The delay in the United State’s adoption of ICD-10 is understandable and can likely be traced to roots of our fragmented payer systems. Many other countries have single payer systems in which there is only one main payer, often the government that provides reimbursement for care that can more easily move towards a common set of codes and measures. While other countries have proven successful at implementation ICD-10 codes, the United States has a large number of managed care organizations invested in systems based upon current coding systems. As a result, providers are too invested in building systems and training staff to use current procedural technology (CPT) codes that document particular procedures or findings that involve the patient. The cost and complexity in transitioning to a new coding system is not only costly, but also a threat to the bottom line of many managed care organizations (4). Providers too are struggling to keep up with the current demands of payers and government coding requirements.
The Canadian and Australian implementations were challenging and led to a decrease in productivity within the reimbursement system (5). Such experiences, in conjunction with the sheer size and complexity of the U.S. system, provide the foundation to predict an impending disaster with ICD-10 implementation. However, these experiences, partly due to physician fear of losing compensation, do not necessarily mean that the United States will share the same fate. The United States has a preexisting infrastructure for training clinicians and coders to learn the new codes. Information systems are far more advanced than they were in years past and will also assist in making a system conversion easier. The experience in incentivizing clinicians with meaningful use programs, a program that rewards clinicians for a certain amount of activity utilizing electronic health records, provides good lessons for the implementation of this transition as well. If the United States waits until ICD-11 becomes available to implement or simply fails to implement ICD-10, we will lag behind other advanced nations in creating and utilizing quality health data to improve patient outcomes. As data can be shared internationally on health outcomes, United States researchers would be unable to compare data with others around the world to better understand population health strategies. (6)
There is little doubt that the ICD-10 conversion will be complex and in many ways costly. (7) However, healthcare reform has already set a new course for our system. Without the ability to accurately measure and define outcomes of care, we are unlikely to know whether these new changes are moving us in the right direction. Healthcare databases, cloud computing, and the ability to process large data will now allow us to take advantage of a more refined coding and documentation system to understand the impact of healthcare reform and for better planning of future service needs.
A the transition to ICD-10 approaches, there are several key items that to be considered (8)
1) ICD-10 is necessary! ICD-9 is outdated (> 30 years old) and produces limited data on medical conditions and procedures as well as limits the number of new codes that can be created as new medical technologies keep rolling out. And waiting to ICD-11 in 2017 would be like skipping steps.
2) ICD-10 coding is logical and must not be looked at in isolation as a payment system; rather it is part of the way that our system will achieve success in context of overall health care reform.
3) ICD-10 is a not optional. Providers who refuse to comply with ICD-10 coding will not get reimbursed for their services, which could result in patients being obligated to pay for the service.
4) There is no grace period. For a provider to get reimbursed for their medical services provided, he/she must use ICD-9 codes until September 30, 2015 and ICD-10 codes on October 1st 2015.
5) CPT Codes are not changing. The main difference is that ICD codes are used for documenting and diagnosing patients while CPT codes, administered by the American Medical Association, dictate payment.
The US healthcare system is advancing to the next stages of health reform and shifting the focus from episodic care to the management of chronic conditions and the prevention of disease. In order for the US system to evolve in a quality manner, it is essential that we move to an ICD-10 system. Documentation of what we do as a system is vital to being able to understand the linkages between resources and outcomes of care. Clinicians need to begin documenting patients’ needs in a more specified manner. It is difficult to improve what you cannot measure and as such our system needs to invest in improved documentation and measures. At the same time, we are seeing unprecedented structural changes in our system as well as advancement in technology. Progress on all of these fronts can make the most significant strides in advancing medical care the United States. (9)
*At the time that this was written, the US Senate passed the Doc Fix Bill, which delayed ICD-10 another year until 2015. (10) Even now, waiting until 2017 to implement to 2017 is unfeasible since ICD-11 will build off of ICD-10. Yet, it is quite plausible that the United States will not be ready for implementation of ICD-11 in 2017.
Daniel B. Shulkin is a Masters of Public Administration candidate in Health Policy & Management at the Wagner School for Public Service of New York University. He is also a Fellow for Health Economics, Finance, and Outcomes Measurement at the Greater New York Hospital Association.