Presented by:
Nelly Leon-Chisen, RHIA
Director, Coding and Classification
American Hospital Association
Chicago, IL 60606
My name is Nelly Leon-Chisen. I am the director of coding and classification at the American Hospital Association (AHA). On behalf of our 5,000 member hospitals, health systems, networks, and other providers of care, I would like to thank you for the opportunity to provide comments on the possible future implementation of the International Classification of Diseases, 10th Revision, Procedure Classification System (ICD-10-PCS).
The AHA’s Central Office on ICD-9-CM serves as the United States’ clearinghouse for issues related to the use of ICD-9-CM. The Central Office on ICD-9-CM was created as a result of a memorandum of understanding between the AHA and the Department of Health and Human Services (HHS) in 1963. It is also the publisher of Coding Clinic for ICD-9-CM. Coding Clinic is the official publication for ICD-9-CM coding guidelines and advice, as designated by the Cooperating Parties. Collectively, the Centers for Medicare & Medicaid Services (CMS), the National Center for Health Statistics (NCHS), the AHA and the American Health Information Management Association (AHIMA) are known as the “Cooperating Parties.”
Accurate and precise reporting of clinical codes is extremely important because the clinical codes are key to benchmarking, quality assessment, research, public health reporting and strategic planning in addition to accurate reimbursement. For instance, ICD-9-CM codes allow hospitals to develop critical pathways for those diagnoses or procedures that are high volume, high risk, or high cost, and those in which the course of treatment is similar between patients. The hospital can determine which procedures are high volume by examining their clinical abstracted data and selecting the ICD-9-CM codes that appear with highest frequency.
ICD-9-CM has been in use for more than 20 years and is long overdue for an overhaul. Many of the new procedures and innovations in medical practice are not adequately captured in the ICD-9-CM. The ability to expand enumeration for a particular procedure category is limited because of the physical numbering constraints contained in the current system. Consequently, some categories provide vague and imprecise procedure codes. Recently, chapters 00 and 17 were opened for the creation of new codes. However, at the current rate (e.g., 24 new codes were created this year) these new chapters will be insufficient to keep up with the need for new codes.
Because of numbering constraints, ICD-9-CM groups several distinct procedures performed on different parts of the body and with widely different resource utilization together under the same procedure code. For example, code 99.29, “Injection or infusion of other therapeutic or prophylactic substance,” has been used to report a variety of procedures such as: an injection of epinephrine to cauterize a rectal ulcer, infusion of a narcotic into a pump for pain relief, insertion of an implant in the eye for slow release of an antiviral drug, and injection into the uterine artery to treat a fibroid. Such vagueness in coding does little to help hospitals, payers or researchers. To identify patterns or treatment procedures, medical records must be pulled and examined. For example, a researcher studying outcomes of antiviral drugs released via implantation in the eye would first need to examine all the medical records with 99.29 to identify the subset of patients that received the antiviral drug – a very labor-intensive task.
More detailed code assignments, made possible by ICD-10-PCS, are needed. They would greatly reduce the administrative burden for hospitals. More detailed codes would:
The timeline for implementing the new system should be carefully orchestrated to minimize the administrative burden to providers. Hospitals are already facing numerous regulatory changes over the next several years, including the Health Insurance Portability and Accountability Act (HIPAA) privacy, security and electronic transaction standards and implementation of new prospective payment systems – all of which will add significantly to hospitals’ burden and costs. Therefore, the ability of hospitals to absorb all of these regulatory changes must be carefully taken into consideration. The vast majority of hospitals are dependent on their hospital information system (HIS) vendors for programming changes. Therefore, the AHA supports the HIS industry in requesting the ICD-10-PCS implementation for procedure coding be carried out in tandem with the migration to the ICD-10-CM diagnosis codes. The AHA also supports their recommendation to implement ICD-10 three years after HIPAA implementation.
Implementation of ICD-10 will be a complex and costly process. Therefore, Medicare, along with other health plans, should be sensitive to these increased regulatory costs and adjust payments accordingly. The AHA believes that the cost of implementing significant new regulations should be worked into the Medicare prospective payment rate updates. Further, we believe that Congress should establish grants to help hospitals with the enormous costs of complying with the HIPAA rules, including conversion to an entirely new coding system such as ICD-10.
For hospitals, the bulk of the cost associated with the adoption of a new procedure classification system will be the costs associated with training personnel. Hospital support staff such as coders and billers will have to attend training seminars to familiarize themselves with the new coding guidelines, rules and definitions. Hospitals will have to work with their medical staff to ensure that the appropriate documentation is available to support the new coding system. ICD-10-PCS code selection requires that more specific and detailed physician documentation be available in the medical record. This greater level of specificity may also require that coders and billers expand their knowledge of medical terminology, anatomy and physiology, and disease process.
Changes to the coding system also require extensive and costly modifications to information systems. Hospitals use a combination of purchased software and in-house developed applications. The software applications that will require modification encompass functions such as code assignment, medical records abstraction, aggregate data reporting, utilization management, clinical systems, billing, claim submission, groupers, and other financial functions. In essence, every electronic transaction requiring an ICD-9-CM procedure code would need to be changed. These changes include software interfaces, field length formats on screens, report formats and layouts, table structures holding codes, expansion of flat files, coding edits, and significant logic changes. Hospitals will have to bear the financial burden associated with software changes as well as possible hardware upgrades. During the transition period, information systems will have to support both ICD-9-CM and ICD-10 (PCS and CM) coding systems, requiring additional data storage space. Small and rural health care providers in particular, many of whom are facing serious financial challenges and have less sophisticated information systems, are further handicapped in their ability to accommodate such changes and may require additional resources and support to help them acquire information and coding system support programs.
The AHA has worked closely with institutional members in the initial informal field testing of ICD-10-PCS. Based on the testing, ICD-10-PCS holds a great deal of promise and should be considered for future use. The AHA believes that before implementation takes place, the new system should be tested for all services in all settings. Thus far, the testing has been limited to primarily the medicine and surgery sections in the inpatient hospital setting. Other sections yet to be thoroughly tested are obstetrics, measurement and monitoring, imaging, nuclear medicine, radiation oncology, osteopathic, rehabilitation, audiology, therapies, and mental health. Further formal Beta testing should be undertaken with coders using real records. Additionally, the testing should also consider the compatibility of the new system with existing payment systems such as Diagnosis-Related Groups (DRGs), Ambulatory Payment Classification (APCs), or simple fee schedules. The AHA expects that the use of ICD-10-PCS will not result in lower reimbursement to providers compared to levels they would receive by using ICD-9-CM.
No decisions should be made, or discussions entertained, regarding a potential single procedure classification system until all contending systems have been thoroughly tested for compatibility with existing payment systems. Such testing should be undertaken by an objective organization, preferably under the direction of the NCVHS.
We ask that you consider the following implementation issues:
Again, thank you for the opportunity to provide comments to you. I will be happy to answer any questions you may have.