By: Barbara Aubry
During its semi-annual policy making sessions, the American Medical Association released its resolutions to stop the implementation of the ICD-10 CM (diagnosis) and PCS (procedure codes) implementation. CMS responded that it does not intend to alter its ICD-10 migration go-live date of October 2013. Specifically, the AMA resolved to “vigorously work to stop the implementation of ICD-10 and reduce its unnecessary and significant burdens on the practice of medicine.” It further resolved that it will “do everything possible to let the physicians of America know the AMA is fighting…on their behalf.” And finally, it announced its intention to work with other national and state medical and informatics associations to determine an appropriate replacement for ICD-9.
What? Are they serious?
My Take:
I’m lucky – my personal physician is willing to talk regulations with me. She and her partners in a large multispecialty group are fed up. Up to their eyeballs in regulatory changes and demands on physicians and ICD-10 seems to be the proverbial ‘icing on the cake.’ She tells me her patients complain about seeing doctors who can’t fully listen to them because they are busy typing in their EHR data entry system. When there is no eye contact some worry their doctor is not hearing them. At the same time, patients like the convenience of electronic prescribing and the overall idea of technically wired medicine, but do not want to give up any of the ‘humanness’ of the doctor-patient encounter.
In my opinion, there’s an issue with ICD-10 that physicians are less willing to discuss and that is its innate demand for greater documentation specificity, which will force them to improve their documentation practices. A very good thing for data accuracy and continuity of care, but it may come at a cost. Documenting more precisely takes time and in medicine as in so many industries, time is money. Will patients be willing to bear an increased cost of a visit with their doctor? Will payers consider the increased amount of time it may take physicians to document patient encounters in ICD-10? Are they willing to increase reimbursement to help make the transition less painful? Finally, will some physicians continue to resist new technology and automated tools, even if it makes the documentation process much easier?
Healthcare providers have heard enough about ICD-10 to know implementation will be a challenge. The AMA appears to be positioning itself as the David protecting the interests of the small physician practice against the onslaught of the governmental Goliath and its demands and regulations. I hope not. At the end of the day, ICD-10 opens up new opportunities for clinical research, business analytics, and better quality outcomes data. Attempts to postpone ICD-10 and avoid technological improvements and advancements will not benefit the patients they serve.
Wonderful post. Since I am a physician and experienced first-hand the adminstrative burden of providing medical care, allow me to share my perspectives and solutions (which, sadly, I do not think will be implemented).
Yes, physicians are frustrated with ICD-9, much less ICD-10; however some of this is their own (and the AMA’s) fault. Let’s tell the truth about ICD-9 and ICD-10; while physicians were asked to provide feedback and advice about their construction, at the end of the day, ICD-9-CM and ICD-10 are not physician languages – they are HIM languages. Yes…no physician governs ICD-9-CM or ICD-10 – it is managed by 4 RHIAs – Donna Pickett, Patricia Brooks, Sue Bowman, and Nelly Leon-Chisen. Donna Pickett has unilateral authority to govern the diagnostic language that physicians must use when they submit codes; no physician can overrule her. Therefore, physicians are frustrated when language we read in our literature, such as heart failure with preserved systolic function or hypertensive urgency and emergency, and the like do not have clinically congruent codes that can be easily assigned without a query.
Second, physicians are frustrated with the query process. It’s as bad as learning inpatient from observation status for patients requiring an overnight stay. All of these seem to be rules that only give excuses for government and payers not to reimburse for care the physician rendered in good faith.
What’s the solution? I believe that there needs to be a 5th member of the Cooperating Parties, which could be the AMA (if they didn’t appear obstructionist) or perhaps another party, such as the American College of Physicians, the College of American Pathologists (who invented SNOMED) or even a rotation of these groups.
I also believe that there needs to be some leeway in coding using defined defintions of terms, much like when nurses clinically abstract records for the STS and ACC databases. If the government disagrees with the code because they do not believe that it fits the clinical circumstances, they can challenge it on the back end. They’re doing it now (disallowing coded based on provider documentation).
The cost savings to hospitals would be HUGE! Look at all the money hospitals pay for concurrent reviewers and their training and such; this money could be invested in the back end, in quality improvement projects, or in reducing the cost of delivering care. Sadly, industries that thrive on the inefficiencies that we have now would have to redirect their business models (full disclosure – I teach CDI, thus I would be affected).
In summary – I share the physicians frustrations. Much of my work is in systems development as to reduce the need for query or to provide query at the point of patient contact. I do believe ICD-10 is a good thing; implementing it without adding the straw that breaks the camel’s back is the challenge that I face.
Thank you for the post……I agree with your take on this situation.
Bottom line, better documentation benefits the patients. As a patient / nurse, I can handle having a little less eye-contact with my physician if it means the information entered about my condition (or those of my family) is timely, accurate and complete. It is also important to me that other members of my care team are able to access these robust details whenever necessary.
Dr. Kennedy’s post correctly expresses the frustration of hospital coders and physicians with queries.
I am a hospital coding supervisor.
I do have one concern – giving all responsibility for ICD-9 or 10 language to 4 RHIAs does not take into account that these systems are originated by the World Health Organization, not USA RHIAs. Guidelines for use are set by cooperating parties which include AHIMA and the AMA. So I am a little confused by the statement that “Donna Pickett has unilateral authority to govern the diagnostic language that physicians must use when they submit codes; no physician can overrule her.” I am saddened if that is the impression that has been given by the RHIAs involved.
The AMA is not one of the 4 Cooperating Parties for ICD-9-CM or ICD-10; their only role is in an advisory role as a member of the Editorial Advisory Board for Coding Clinic. Where the AMA has control is with CPT, not ICD-9-CM or ICD-10.
While the WHO sets the template for ICD-10 or ICD-11, its modification for use in the United States, ICD-10-CM and ICD-10-PCS, is governed by the 4 RHIAs that I mentioned (the 4 Cooperating Parties are the CDC, CMS, AHIMA, and AHA). Believe it or not, Donna Pickett, RHIA, has the final and unlimited authority to determine what goes into ICD-10-CM and Patricia Brooks, RHIA, has the final and unlimited authority to determine what goes into ICD-10-PCS.
Physicians are frustrated that ICD-9-CM or ICD-10 does not keep up with their literature. Witness the whole issue about acute kidney injury and its stages, especially if it is associated with a specified renal pathology like lupus nephritis. Look at how one would code “hypertensive urgency” or “heart failure with preserved systolic function”. Physicians are tired of the query process, even though they recongize its importance.
Thank you for your comments. One of the great things about change is that it forces us to refocus and find ways to improve – even when we are too busy to deal with the status quo. Change can be invigorating and result in improved processes and decision making. Perhaps it would be beneficial for a physician organization to become more involved in the governance of ICD-10 CM and PCS going forward? They could better serve their members by bringing the clinical technological advances to the mix as codes are created. As a former Utilization Review nurse, many coding queries found their way to my desk – especially from the PROs. I also had to query physicians and I understand the frustration with the process. As a nurse working in a pain management practice, I shared the frustration of the physicians when new procedure techniques could not be coded simply because there was no code to represent the new process. The patients needed the care and the coders did the best they could within the limits of the code sets they had to work with. The new language provides a lot more flexibility and specificity and I hope it will better align all stakeholders in the steps required for fluency since at the end of the day, we are all learning it together.
the ICD -10 codes were started in 1993. Instead of blocking the adoption of ICD-10 at the last hour, the AMA should have participated in the creation of the codes and offered educational programs so everyone would be ready. They own CPT codes and offer very little to anyone as far as educational programs and they also own the CME credit process. They choose to be behind in the times. Their CPT coding products are still in book form and there is a rare product that is electronic. They choose instead to license out the codes and live on the royalties. I find this hypocritical. Now at the eleventh hour, when all new versions of electronic medical records will have ICD-10 and ICD-9 codes in one place are they putting up the resistance.