The ICD-10 Extension: For Whatever Reasons, Congress Did the Right Thing.

flying cadeuciiDid you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.

Good thing he didn’t say an act of God.

So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?

The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.

First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.

An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.

“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”

“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”

And there you have it. The Have-a-lots have prepared, invested millions and are now wringing their hands over the delay. And why shouldn’t they? They’ve gone so far as to help their docs understand how comprehensive SNOMED CT terminology helps them be specific and accurate.

Now they want to finish the project.

On the flipside, the Have-nots have been given a reprieve from the potential financial catastrophe predicted by the HIMSS/WEDI ICD 10 National Pilot report:

The “perfect storm” will be quickly descending upon the healthcare system … All ICD-10 impacted organizations should act now to allocate as much time as possible for testing and remediation to protect their corporate bottom lines and cash flow to successfully achieve compliance.

The reimbursement hit for foundering Have-nots would put their narrow margins into the red. Their physicians would struggle with trying to code without adequate training and tools, further eroding time with patients. Even the Have-nots with EHRs still lack the resources to fully prepare and train for both MU Stage 2 and ICD-10 this year. The EHR and coding technologies are essential tools but results are based on preparation and change management, i.e., services and time.

In a statement released following the ICD-10 delay, New York-based financial information services company Fitch Ratings described the one-year extension of ICD-10 as a “positive credit development” for not-for-profit hospitals. The statement recognizes the significant investment many hospitals have made, but still warns against potential disruption of the revenue cycle and the disproportionate impact this could have on the Have-nots.

While a majority of providers have made the substantial investment in technology and personnel to be ready for the transition, the readiness of both governmental and commercial payers to adequately process claims and payments in a timely manner has been questioned. In our view, lower rated credits would be more susceptible to this risk as they have less financial resources to absorb a potential delay in reimbursement.

With the ICD-10 delay, we avoid putting a significant portion of our provider organizations out of business; we assure the patients of many safety net organizations that they still have a place to receive care.

But is there a risk that we get into a series of rolling delays and extensions?  The danger is real. The World Health Organization says ”the 11th revision process is underway and the final ICD-11 will be released in 2017.”

ICD-9 was released in 1979. ICD-10 in 1999. While most countries that aren’t the US adopted ICD-10 upon release, we are still extending, which gives rise to some serious questions: When will ICD-11 be mandatory in the US? How long will it take for products and systems to be ready?  How many years on ICD-10 is worth the cost before changing again?

We know that the Have-a-lots are migrating to and using ICD-10 now, and we can feel confident that they will continue moving forward to ICD-11. For the Have-nots, Congress may have to come to the rescue again.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the developer of the OpenVista electronic health record.

13 replies »

  1. I have read all the comments which mentioned above. I am an EHR developer now a days working for http://www.nortecehr.com. As a software developer i believe the delay is not good because we complete our home work. But if i think as the IT manager of small hospital or clinic i simply love this delay.

  2. Our practice added IMO a program that interfaced with the EHR and interpreted the diagnoses of the provider. Our providers really like it. It also gives the recommended ICD10 code for the diagnosis in addition to the ICD-9 to prepare clinicians for the eventual changeover. https://www.e-imo.com/

  3. “We have long expressed serious concerns about ICD-10’s functionality and the real potential for technical problems that could result in delayed payments for physicians,”

    “Any problems in processing payments would be especially devastating for solo and small family physician practices.”

    “The “perfect storm” will be quickly descending upon the healthcare system … All ICD-10 impacted organizations should act now to allocate as much time as possible for testing and remediation to protect their corporate bottom lines and cash flow to successfully achieve compliance.”

    Too costly for everyone, but has anybody really took on some huge impact that this would offer to the patients? Haven’t found anything from the net yet. When I searched for ICD-10 all I read about is the advantages and disadvantages it may present to medical practitioners and health professionals alike. Just sayin.

  4. And an example of such a program is….?
    Even with current IMO, SNOMED etc, you still have to know what it is looking for.
    The pizza example is accurate.

  5. Agreed, the key technologies needed to get docs out of the coding business are great smart search and natural language mark-up with clinical auto-coding. Have the computer do the coding derived from the care.

  6. Like most good practicing physicians, she is far from obsessed with coding. She is just very busy and wants to take care of patients not code records. She used to have to spend time manually modifying back or abdominal pain to describe right flank pain. She has found the ICD 10 coding more specific clinically. She does not have to worry that what she mocked up will get paid or not or whether it would be represented in the problem list accurately. Just clinical and practical benefits.

  7. Perhaps Google can build a search engine for ICD-10 codes. We could then have our notes auto-coded the way Dr Val suggests.

    Or, while we’re at it, perhaps our notes will be unnecessary, with such specificity in our coding….that would eliminate the distractions that go with seeing every patient and every disease process as unique.

  8. Andy’s link should be mandatory reading: http://www.kevinmd.com/blog/2014/04/icd10-emperor-clothes.html

    I understand the importance of coding, but currently the terminology search paths don’t correlate with how physicians actually think. Locating the “right code” becomes a lengthy and exasperating exercise.

    It’s like searching for the word “pizza” and finding that it can only be accessed by looking up “oven-baked products” then “wheat-based” then “with dairy.” I fear that ICD-10 will add several additional layers of complexity so that a pizza is going to need to be qualified by every herb in the sauce, the weight of the slice, and the grams of fat per unit!

    That level of detail may or may not be useful to data crunchers – in theory, it could help them determine how much basil the country *may* be consuming in the next calendar year… But more likely the pizza makers (faced with a crowd of hungry patrons looking for speedy service) will just select the easiest codes so they can move on with their work. In the end, we won’t really learn much about the kind of pizzas being produced, because they’ll all be coded as plain cheese.

    Wouldn’t it be better to create a system that can code automatically, based on typed notes? Maybe it’s too complicated to do that correctly – but that’s what we should be aiming for.

    Until then, I’ll be seeing fewer and fewer patients because I’m already so busy searching for sub-types of pizzas under “o” for “oven-baked goods” in ICD-9. I can’t even imagine the world of pain that’s in store with America’s version of ICD-10.

  9. I wonder why your physician is so obsessed with the accuracy of her ICD coding. Doesn’t have much to do with outcomes.

  10. I think the consensus is ICD-10 was just one thing in the year of too many things.

  11. I would like to believe in progress in technology and standards, but I am sorry to say I’m coming around more and more to the opinion expressed in this blog, whose author says we’re not even using ICD-10 the way other countries use it:


    I would like to see a system with fewer codes but separate fields in Semantic Web fashion to quality the codes. Why can’t “right” versus “left” be a general choice to apply to any code? Why not link conditions so show that one condition contributes to another, instead of jamming them in one code?