Stop Complaining About ICD-10 and Start Training

Misinformation and misunderstandings surround ICD-10 as the go-live date nears. One result is that too many providers have yet to conduct testing. They should take advantage of CMS's grace period, starting now.

The announcement yesterday that the American Medical Association is now working jointly with CMS to educate its membership about ICD-10 is better late than never.

Consider that, according to a survey conducted by the American Health Information Management Association (AHIMA) between May and June, the majority of providers have not yet conducted ICD-10 testing. This annual survey found that 19% of respondents do not even plan to conduct any end-to-end testing.

That is a fairly astounding finding, nearly as astounding as some of the continuing misinformation being circulated about how coding errors in ICD-10 will affect physician's payments. For some clarification on this, I again turned to AHIMA.

"ICD-10 has very little to do with physician payment," says Sue Bowman, AHIMA senior director for coding policy and compliance. "On the hospital side, it drives the DRGs and all kinds of payment issues. On the physician side, their payment rates are driven by the CPT codes."

ICD-10 diagnosis codes do determine medical necessity, and wouldn't we want those to be properly coded? I am puzzled by the continuing procession of physicians who speak of having to document their procedures in the ICD-10 procedure coding system (PCS). "It's not true that [physicians] have to document in ICD-10 PCS lingo," Bowman says. "There's actually a coding guideline that says the physicians can document their procedures the way they always have, and it's up to the hospital coder to translate the physician's description of [procedures] to ICD-10 PCS codes. But only hospitals are going to be using those codes, not physician practices."

One big irony of some recent criticism of the specificity of certain ICD-10 codes themselves, Bowman says, is that specificity was itself inserted into ICD-10 PCS by physicians, through specialty societies.

Yesterday's announcement that CMS would not deny claims for the first year of ICD-10 due to lack of specificity, along with AMA's acquiescence to working with CMS to educate its members, will immediately take the wind out of the sails of the usual movement to postpone ICD-10. In a June letter to CMS, the four largest state medical societies (California, New York, Florida, and Texas) declared ICD-10 a "looming disaster." Denied and delayed claims could bankrupt many small physician practices, the societies said.

Proposed physician relief in this letter and in H.R. 2247, the ICD-TEN Act, would have permitted claim payments and withholding of penalties despite any errors and mistakes in ICD-10-coded claims submissions for up to two years, and to withhold Recover Audit Contractor (RAC) audits related to ICD-10 coding mistakes during that period of time.

The fear was that overbroad relief could have opened the floodgates to a rash of Medicare payment fraud during such a two-year period.

Another part of H.R. 2247 would prohibit Medicare from denying claims due to "the use of an unspecified or inaccurate subcode." Bowman and the Coalition for ICD-10 (of which AHIMA is a member) point out that CMS accepts clinically accurate but less "granular" code under both ICD-9 and ICD-10. Bowman points to a CMS "Medicare Learning Network Matters" posting that acknowledges that clinicians do not know any more than a particular level of detail, which can continue to be represented by the unspecified codes.

Perhaps for all of the above reasons, the AMA has now chosen to work with CMS instead of continuing to fight the inevitable.

Finally, I continue to hear a constant refrain that ICD-10's focus on billing yields no benefits to the quality of healthcare. I asked AHIMA to weigh in on this continuing criticism.

"There's a lot of research analysis that's done based on claims data that uses that diagnosis and procedure data for a lot more ways than beyond just how that claim got paid," Bowman says, "to be able to assess difference in resource utilization, difference in outcomes for different kinds of treatment, [and resolving] patient safety issues."

AHIMA CEO Lynne Thomas Gordon, herself a former hospital administrator, adds that ICD codes help hospitals with strategic planning, including capital construction, service line creation and termination, and quality measures. "When we move to population health and value-based purchasing, we're going to need to use these codes to say, Okay, what's going on in our population?" Gordon says. "What are we seeing with the patients that we serve? Are we seeing a lot of infection rates? I could just go on and on."

I am left wondering: if ICD-10 is so critical to quality measures, why are many other quality metrics that are not based upon ICD-10 sitting in certified EHR software? I chalk that up to something CMS, other payers, and the rest of healthcare and public health desperately need to clean up: the many overlapping and redundant quality measure reports putting a severe burden on providers of all sorts.

But main point is that, with fewer than 100 days to go until the go-live date of October 1, all providers should be testing ICD-10. If they are not, they need to get going now. Undoubtedly, those organizations with fewer resources will be the most severely challenged. They should make the most of CMS' one-year grace period and tap the additional resources now offered by AMA and CMS.