Jori Frahler07.20.06
Adoption of New ICD-10 Coding System Comes Down to One Question: Sooner or Later?
Jori Frahler, JD
For many device manufacturers, coding perhaps is an issue best left to reimbursement experts. However, changes to a 30-year-old system are being debated in Washington that will impact the medical provider, medical device sector and the patient, and will influence how technology—particularly novel technology—is accounted for in the United States.
Originally developed by the World Health Organization to track both morbidity and mortality, the current version of the International Classification of Diseases Ninth Edition (ICD-9) was published in 1977. Thirty years ago, with the introduction of ICD-9, the coding system was able to precisely delineate the clinical picture of a patient. The issue of the International Classification of Diseases 10th Edition Clinically Modified diagnostic coding system (ICD-10-CM) and procedure coding system (ICD-10-PCS) is generating a lot of discussion on Capitol Hill.
For those in the medical technology industry, ICD-10-PCS is important because the current coding system, ICD-9, is not only outdated but quickly running out of codes. As modern medicine has progressed and medical technology has become more sophisticated (to the point where implantable devices are commonplace), ICD-9 has become obsolete.
Current System Is Obsolete
Moving to ICD-10 is not a new concept. In 1993, the National Committee on Vital and Health Statistics (NCVHS), the CDC’s National Centers for Health Statistics and the Centers for Medicare and Medicaid Services (CMS) developed a transition plan for ICD-10. In addition, the majority of industrial nations and more than 100 countries worldwide are already using ICD-10 to report mortality data. As such, the United States’ use of the antiquated ICD-9 system is problematic because our data are incompatible with the rest of the global community.
Furthermore, failure to use the international standard for collection of diagnostic data severely weakens our ability to track and respond to external public health and bioterrorism threats. This could have severe implications with the looming threat of an avian flu outbreak. Should such a global outbreak occur, the United States would be ill-equipped to assign proper diagnostic codes to the disease, potentially adding a layer of chaos to the healthcare system.
Along with the introduction of novel medical technologies, significant progress has been made toward improving the US health information technology (IT) infrastructure. As a result of improved health IT, the terminologies and classifications from the 1970s no longer work with a 21st Century healthcare system.
Moving to ICD-10 will not only expand the current code set from 24,000 codes to 207,000, it also will allow for a more detailed description of procedures. For example, the sixth digit of the seven-digit ICD-10-PCS code reflects the use of a device that remains in a patient after completion of a procedure. This level of specificity is needed to allow for precise tracking of device-dependent procedures.
Beyond the need for global harmonization of diagnosis codes, this level of specific coded health data serves as a foundation for billing, claims processing, pricing and payment. Therefore, utilization of such an outmoded coding system is problematic for several reasons. First, in an era of quality measurement, pay-for-performance and transparency in the hospital setting, ICD-9 does not accurately reflect the procedures performed by physicians. Second, as new technologies are developed, the ability to get a code is becoming more difficult, causing the assignment of a code to look much more like a coverage decision rather than merely a code. Third, the interoperability of health information systems is severely inhibited, since the United States is using an older coding system.
In 2003, in an effort to encourage the United States to move toward ICD-10, the NCVHS again vocalized its position that ICD-9 was “increasingly unable to address the needs for accurate data for healthcare billing, quality assurance and health services research,” and that it was “in the best interests of the country” to move expeditiously to replace it. With the continued delay to move to ICD-10, it has become clear that Congress must pass legislation mandating its adoption.
Lawmakers Getting Involved
Last October, Ways and Means Health Subcommittee Chairman Nancy Johnson (R-CT) introduced H.R. 4157, the “Health Information Technology Promotion Act of 2005.” This legislation provides for the adoption of ICD-10 in October 2009. Surprisingly, however, this provision is causing quite a debate on Capitol Hill.
Currently, both the House Ways and Means Committee and House Energy and Commerce Committee have shared jurisdiction over this bill, and each committee has marked up its version of it. But the Energy and Commerce legislation does not include a provision calling for the adoption of ICD-10. The medical device industry is continuing its efforts to pass legislation adopting ICD-10 during this Congress.
Industry players are not the only ones vocalizing concerns with the antiquated coding system. During the recent 12th annual meeting of the Medical Device Manufacturers Association (MDMA) in Washington, DC, CMS Administrator Dr. Mark McClellan described the current coding system as “bursting at the seams.” Other CMS officials have additionally described ICD-9 as “antique” because it no longer accurately describes the diagnosis and procedures of care delivered in the inpatient hospital setting.
With the push toward adopting national electronic health records, interoperable information networks will require modern classification systems for summarizing and reporting health data. Equally important, ICD-10 would allow hospitals to track patient care processes and enable accurate reimbursement—potentially eliminating fraud and abuse in the healthcare system. Expanding and improving the coding system also would provide the CMS with more flexibility and accuracy in its nomenclature, especially in identifying the broad range of new medical technologies, and would reduce the time lag for introducing codes for new procedures into the claims processing system.
Why the Debate Continues
Certain stakeholders have raised concerns about the cost and administrative burden of implementing more than 200,000 new diagnosis and procedure codes. Some also are apprehensive about the cost of upgrading computer systems and retraining coders. Such arguments only delay the inevitable, however, because all parties agree that the move to ICD-10 must occur at some point.
Therefore, the debate is really about when to implement it. Those opposed to the adoption of ICD-10 in 2009 are advocating for a 2012 implementation date. Yet, supporters of ICD-10 believe that six years is too long to wait, especially since this debate has been ongoing since 2000.
As legislators try to move toward a compromise, stakeholders with a vested interest in seeing ICD-10 implemented sooner rather than later have put forward recommendations. A coalition of Washington-based associations (MDMA, AdvaMed, American Health Information Management Association, Federation of American Hospitals and American Hospital Association) continues to stress the importance of this issue on Capitol Hill. Specifically, the coalition is supportive of implementing ICD-10 in 2009 because the expanded code set will provide more accurate and detailed clinical information that can improve quality measurement and patient safety activities while allowing for more accurate reimbursement—helping to identify and reduce fraud.
Regardless of whether the House of Representatives decides to act now and pass legislation promoting the adoption of ICD-10, one thing is clear: The current system is outdated, and not only are the multitude of stakeholders affected, ultimately the federal government is impacted because the current coding system is not meeting the US healthcare data needs.