Sunday, April 19, 2015

National Countdown to ICD-10: A Status Report

DISCLOSURE: Reminder that I am a practicing physician, hospital/health system administrator, and also the Chief Medical Officer of a CDI/ICD-10 vendor called ICDLogic.


Now that the Sustainable Growth Rate (SGR) Bill has been repealed by congress and is expected to be rubber stamped by Senate and President Obama, it is with mixed feelings with which I write about the status of ICD-10 in our nation.  As the US healthcare system scrambles in these last few months to prepare for the transition, my feelings as a vendor are self-explanatory.  My roles at my hospital and health system brings feelings of vindication as all our preparatory work will not go wayside again.  As a data junkie, the more data I have, the more information I can create.  So, as long as the entered data is valid and ACCURATE, the analytic part of me is excited about the opportunities that ICD-10 will bring.  Researchers, most healthcare vendors, and payers are of the same mind-set.  Needless to say, so is the Center for Medicare Services (CMS).  The hope by all is that more specific documentation will give us the data we need to help us manage and improve the care our providers deliver to our patients.

However, as a practicing physician I am fearful.  Not so much for my own practice but for all my physician brethren (and sistren of course).  This post outlines my fear and briefly presents my concerns.  As with any blog, these are my opinions and I don't consider myself an expert.  I would be greatly appreciative if anyone tried to allay my fears- please comment below.

Who cares? What's the big deal?

CMS has advised that all healthcare organizations have THREE months revenue on hand in preparation for ICD-10 transition...  With the average solo-practitioner having maybe $30k per month in revenue, I would bet that the majority do NOT have $100k in their rainy day fund.  Delays in payment to these providers can be catastrophic to their communities and will redirect patients to others.  Many of which are already booked solid for months on end.  Finally, the "nice guys" that accommodate are doing so by reducing their availability to their existing patients- namely you and me.  The point of this is that we're all in this together.

How will ICD-10 change practice?

Asthma is a fairly straightforward clinical disease to diagnose and treat.  Coding in ICD-9, however is a different story but one that most providers become very proficient at after some practical experience.  There are essentially five ICD-9 codes for asthma, each having 3 subtypes gives a total of roughly 15 codes to choose from.  Description of asthma in ICD-10 has over 50 options and will require additional specification to meet reimbursement criteria, namely one of the following:
  • Exposure to environmental tobacco smoke (Z77.22)
  • Exposure to tobacco smoke in the perinatal period (P96.81)
  • History of tobacco use (Z87.891)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Tobacco dependence (F17)
  • Tobacco use (Z72.0)
Also worthy of mention is that the language of ICD-10 is a coding language, that is, suited for medical coders, not so much for typical clinical staff, especially doctors who speak essentially a different language and need to learn the codes.  This and the sheer volume of options will require much more thought from the provider to first document, then select the correct diagnosis (and code) even though the treatment and management of any subset of them varies little (if at all).  More intimidating is that the additional criteria are not "related" to asthma in that providers don't have an easy way to know or be reminded that these criteria MUST be specified.  In the ICD-9 world, paper job-aids are often littered all over the office reminding providers and staff to document the right information.  However, in ICD-10 the volume of new documentation will require electronic systems to support this activity.  Time (and cost) spent on these systems is time spent away from you and I as patients!  In a world where the amount of time spent at the bedside continues to plummet, this adds insult to injury.  These issues can not be under-emphasized and will sincerely debilitate medical practices that do not prepare in advance for them.

My Concern

If we don't comply with the mandate, we will not be paid!  No ifs, ands, or buts, NO BUSINESS, HOSPITAL, or MEDICAL PRACTICE CAN SUSTAIN NON-PAYMENT!!

I worry least about Hospital-based providers that are a part of a large health system as they have tremendous resources to help prepare their providers.  Independent hospital-based providers will also be OK as they too have help.  It is the independent providers and group practices that I'm concerned about most, currently about 60% of our healthcare system!  As one of them, we don't have any help!!  More importantly, we don't have any one TELLING us we NEED help!!  This is very alarming to me and is the basis for my authoring of this post.

The issue of awareness is more complex than it sounds.  Yes, the aware providers who understand the effect of the transition are seeking out assistance as we speak, but what about those that are not aware?  Well, leaders like myself are paid to reach out to them one by one offering assistance.  But there is a significant chunk of providers that either cannot be reached and/or go out of their way NOT to be reached.  It's very possible that your doctor may be one of these people.  And if they are still documenting on paper, they will have tremendous difficulty preparing, even after they become aware.  With five months remaining, these people are in deep trouble, and they don't even know it.

What about Technology?

Fortunately, there are tools, including ICDLogic's Cypher, which are fabulous in supporting aforementioned colleagues that are trying to stick with the program.  There is also ComplyMD and Provation and 3M and a number of other emerging vendors, each with their own strengths and weaknesses.  The astute reader will notice I did NOT include the major EHR vendors here...  bringing me to my final fear about the impending ICD-10 transition date.

Most of the major electronic health record (EHR) vendors have completely missed the boat here.  Up until recently, when the average CMIO reached out to the average EHR-vendor, the average response is "you're covered by IMO".  Intelligent Medical Objects is a prominent terminology vendor that the majority of hospitals that have EHRs already subscribe to.  But the truth is that IMO is far from a comprehensive solution as it only "powers" the functionality that is inherent in the EHR itself.  This is not completely the truth as some EHR vendors are more thoughtful than others, but I have yet to find a solution that is anticipated to be bump-free.  And I have seen multiple vendors make promises that they are far from delivering on in April 2015.

Given the asthma example above, it should be easy to see that what was previously a list of 15 choices will now be a list of 50 choices for asthma, hundreds of choices for other more common conditions like diabetes, and THOUSANDS of choices for procedures like knee replacement or cardiac catheterization- when's the last time you scrolled to the SECOND page of a Google search result let alone the 15th?  Even you are willing, this approach is WITHOUT any mention or guidance of the "additional" diagnoses that most payers will require to consider the documentation complete.

The Solution

SNOMED CT- see my next blog post for more details


As we are all patients, those of us that love and appreciate our doctors and want them to be around after ICD-10 becomes official should inquire with them about their preparatory plans.  Aside from showing empathy liberally, actively inquiring is the best way for patients (and administrators) to support our providers.  Direct them to local experts and ask them to check in with their billing colleagues to make sure they are "dual coding" in preparation for the transition date.  Although it is a costly exercise, this is one of the most effective things any practice can do to prepare.  

As for me, in addition to the carefully devised, systematic approach I am taking on behalf of the various stakeholders I serve in my other roles, I will also cross my fingers and hold on to my lucky rabbits foot while making a special prayer in the name of the US Healthcare System.  No level of support is too little for us to be prepared for what is currently still considered the ominous date of October 1, 2015.