Chairman Cohn, members of the National Committee on Vital and Health Statistics (NCVHS) Standards and Security Subcommittee, ladies and gentlemen, good afternoon. I am Sue Prophet, director of coding policy and compliance of the American Health Information Management Association (AHIMA). On behalf of the Association, thank you for allowing us this opportunity to provide input on replacing the ICD-9-CM diagnosis coding system with ICD-10-CM.
As you know from our previous testimonies, AHIMA is a professional non-profit association of more than 41,000 members who manage patient information in the form of health records and databases in provider, health plan, government, and private organizations. AHIMA recognizes the significant importance of coding and coding standards, and consistency of healthcare diagnostic and procedural coding is one of our Association’s key issues (see Attachment One).
Relevant to our comments today, AHIMA member responsibilities include a variety of medical coding functions. The classification of medical conditions and procedures is part of the core of the health information management profession. A survey of our active membership shows that nearly 50 percent cite coding as one of their primary job functions, whether they manage coding functions, or are a coding professional or a consultant. From the 1930’s, AHIMA members have been engaged in the use of medical coding as managers and coding professionals. To identify our perspective further, we have included an attachment (Attachment Two) with additional information on how AHIMA members are educated and involved in professional coding. For more information, I invite you all to visit our Web site at www.ahima.org.
AHIMA is proud to serve as one of the Cooperating Parties, along with the Centers for Medicare and Medicaid Services (CMS), the American Hospital Association (AHA), and the National Center for Health Statistics (NCHS), who are responsible for developing guidelines and direction for the proper application of ICD-9-CM. This relationship began in the 1960s, and each of the organizations represented has always been dedicated to enhancing data integrity and consistency of coding. This is a very challenging job, and one that has become immeasurably more difficult in recent years.
In addition, it is appropriate for me to let the Subcommittee be aware that AHIMA is actively involved with the CPT editorial panel, the International Federation of Health Records Organizations (IFHRO), and the International Medical Informatics Association (IMIA).
Today our testimony is directed at the replacement of ICD-9-CM diagnosis codes with ICD-10-CM. Today as we discuss ICD-9-CM diagnosis codes and this system’s potential replacement, we must keep in mind not only the current uses of this system, but also the mandated uses under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
In our testimony today, I’ll cover AHIMA’s perspective on:
ICD-9-CM is a US modification of the International Classification of Diseases, Ninth Revision (ICD-9) developed by the World Health Organization (WHO). ICD-9-CM is the most common and universally applied classification system for coding diagnoses, reasons for healthcare encounters and health status, and external causes of injury. It has broad acceptance and usage and is widely distributed at low cost by multiple vendors. The regulations regarding electronic transactions and code sets promulgated under HIPAA specify ICD-9-CM as the medical code set standard for diseases, injuries, impairments, other health problems and their manifestations, causes of injury, disease, impairment, or other health problems.
AHIMA believes that adoption of a replacement for the ICD-9-CM diagnosis codes is an absolute necessity, as ICD-9-CM is more than 20 years old (implemented in 1979) and has become outdated and obsolete. It is no longer able to meet the many needs for accurate and complete data in this country. Terminology used in ICD-9-CM and the classification of some conditions are outdated and inconsistent with current medical knowledge. The system is rapidly running out of space and is unable to accommodate many new codes to address the need for greater specificity, advances in medicine, and new diseases. In some cases, meritorious new code proposals have not been implemented simply because there is insufficient space for a new code. ICD-9-CM diagnosis codes do not provide sufficient clinical detail to describe the severity or complexity of diagnoses, nor does this system provide sufficient codes for healthcare encounters for reasons other than treatment of disease, such as preventive medicine.
It is difficult to exchange healthcare diagnostic data with healthcare professionals around the world since many countries have already implemented ICD-10 or are in the process of doing so. Continued use of ICD-9-CM causes significant difficulty in comparing international data used in public health, research and development, and the study of issues related to quality, safety, and efficacy of medical care. Our ability to compare mortality and morbidity data within the US is compromised, as ICD-10 has been used in the US for mortality statistics since 1999.
ICD-9-CM no longer meets the most basic definition of “fitness for use.” In the HHS proposed rule for electronic transactions and code sets, promulgated under HIPAA (Federal Register, Vol. 63, No. 88), HHS noted that ICD-9-CM does not meet all of the HIPAA requirements for adopted standards. In particular, they noted ambiguity, lack of precision, and lack of desired level of flexibility. They recommended that steps be taken to improve the flexibility or replace it with a more flexible option sometime after the year 2000. It was also stated in this rule that changes will be required to address current coding system deficiencies that adversely affect the efficiency and quality of administrative data creation and to meet international treaty obligations.
The uses being made of coded data today go well beyond the purposes for which the system was designed or even contemplated in the 1970s. Coded data are used for:
The need for greater coding accuracy and specificity has heightened considerably since the implementation of ICD-9-CM. ICD was primarily used in the hospital inpatient setting for indexing purposes at the time ICD-9-CM was implemented. Therefore, this system is woefully inadequate for meeting the needs of non-inpatient hospital settings or serving the many other purposes for which ICD data are currently used. ICD-9-CM codes were not used for reimbursement purposes until well after the system’s development and implementation. Once prospective payment systems came into existence, the concerns of data quality, coding education, and medical record documentation received new emphasis. The consequences of inaccurate claims data in a fee-for-service environment had not been nearly as critical. Today, several prospective payment systems (PPS) for different healthcare settings have been implemented, including the acute-care inpatient hospital setting, hospital outpatient services, inpatient rehabilitation facilities, and home health services, which depend heavily on ICD-9-CM diagnosis codes. The soon-to-be-implemented PPS for long-term care hospitals, which is modeled after the acute-care inpatient hospital PPS, is also based on ICD-9-CM codes.
Many non-PPS payment methodologies require complete, accurate, and detailed coding in order to negotiate or calculate appropriate reimbursement rates, determine coverage, and establish medical necessity. Once claims data became more reliable due to the increased accuracy and specificity demanded by reimbursement systems, coded data reported on claims began to be used for all of the additional purposes mentioned above.
Daily, healthcare entities (providers, payers, researchers, other users) face problems caused by continued use of an obsolete diagnosis coding system:
The history of statistical healthcare classification systems dates back to the 18th century. The Bertillon Classification of Causes of Death was developed in 1893. In 1898, the American Public Health Association recommended that it be adopted by registrars in Canada, Mexico, and the US and that the classification be revised every 10 years. Subsequent revisions were titled the International Classification of Causes of Death. Until 1948, the classification was only used to classify causes of mortality. At this time, the sixth revision was published under the auspices of the WHO and the scope was extended to include morbidity data. At the time of the sixth revision, the adoption of a comprehensive program of international cooperation in the field of vital and health statistics was recommended. As part of this program, it was recommended that governments establish national committees on vital and health statistics to coordinate the statistical activities in their countries and to serve as a link to the WHO.
The current purpose of the ICD is to promote international comparability in the collection, classification, processing, and presentation of health statistics, including both morbidity and mortality. In practice, the ICD has become the international standard diagnostic classification for all general epidemiological and many health management purposes. The US is required to report morbidity and mortality data to WHO using the ICD under an agreement with the WHO that has the force of an international treaty. The purpose of ICD revisions is to stay abreast with medical advances in terms of disease nomenclature and etiology. While the introduction of new classifications is costly and causes major disruptions in mortality and morbidity statistics, it is essential to stay abreast of advances in medical science and to ensure the international comparability of health statistics.
The ICD or its forerunner has been used in the US to classify mortality data since the end of the 19th century and for morbidity data since the 1950s. Prior to the mid-1950s, the Standard Nomenclature of Diseases and Operations was the predominant coding system for morbidity data in the US. Currently, the ICD is used in all healthcare settings for diagnostic data reporting and analysis, as well as for reimbursement, clinical and epidemiological research studies, public health reporting, and vital statistics reporting.
The WHO promotes the development of adaptations that extend both the usefulness of the ICD and the comparability of health statistics and, therefore, has authorized the development of an adaptation of ICD-10 for use in the US. The US has been developing its own adaptation of ICD since the seventh revision in the late 1950s. All modifications to ICD-10 must conform to WHO conventions for the ICD.
ICD-10 contains the most significant changes in the history of ICD. It is the first new diagnostic coding system since the widespread use of computers in healthcare. With the development of ICD-10, the title was amended to “International Statistical Classification of Diseases and Related Health Problems” in order to reflect the progressive extension and scope of the classification beyond diseases and injuries. ICD-10 differs from ICD-9 in several ways:
The US began using ICD-10 to code and classify mortality data from death certificates in January 1999. The conversion from ICD-9 to ICD-10 had an effect on those responsible for coding death certificates and the mortality data as a whole, including the revision of instruction manuals and the development of new medical software to replace the manual coding process. The NCHS created special software to automate the coding of medical information on the death certificates, according to WHO rules.
ICD-10-CM represents a significant improvement over both ICD-9-CM and ICD-10. It incorporates much greater specificity and clinical detail, which will result in major improvements in the quality and usefulness of the data for all the purposes mentioned earlier. The new alphanumeric-structure coding scheme provides a better structure, allowing considerable space for future revision without disruption of the numbering system, much more than is possible with ICD-9-CM. Notable improvements in the content and format include:
ICD-10-CM maintains many similarities to ICD-9-CM. It has the same hierarchical structure as ICD-9-CM. Many of the conventions are also the same. Primarily, changes in ICD-10-CM are in its organization and structure, code composition, and level of detail.
The 1993 NCVHS annual report noted that ICD-9 was rapidly becoming outdated, worldwide support and maintenance of the classification was expected to terminate, and ICD-10 represented significant improvements in coding primary care encounters, external causes of injury, mental disorders, and neoplasms. Therefore, NCVHS recommended that HHS immediately commit resources to assess the applicability of ICD-10 for coding morbidity, identify problem areas and make modifications as necessary, and develop implementation plans. During 1994, the NCVHS Subcommittee on Medical Classification Systems addressed the need to commit resources to prepare for the implementation of ICD-10 for morbidity and mortality.
A new code set today must meet the requirements for adoption and maintenance set forth by HIPAA – ICD-10-CM meets these criteria. (See Attachment Three for the criteria necessary for a code set adoption as a HIPAA standard).
Most of the problems that exist in ICD-9-CM are addressed in ICD-10-CM. ICD-10-CM provides much better information for non-hospital inpatient encounters, clinical decision-making, and outcomes research. Medical advances that have occurred between implementation of ICD-9-CM and today have been incorporated. Terminology and disease classification have been updated to be consistent with current clinical practice. Coordination and Maintenance Committee recommendations for new codes that could not be added to ICD-9-CM due to space limitations have been incorporated in ICD-10-CM.
In some chapters, a sixth character has been added, further increasing the system’s flexibility. Newly recognized conditions and conditions that are not uniquely identified in ICD-9-CM have been given codes. Conditions with a recently discovered etiology or new treatment protocol have been reclassified to a more appropriate chapter. For example, gout is classified to the Endocrine System chapter in ICD-9-CM, but is classified to the Musculoskeletal System chapter in ICD-10-CM. Bradycardia is classified to the Circulatory System chapter in ICD-9-CM, but is classified to the Symptom chapter in ICD-10-CM.
Codes for injuries and postoperative complications have been expanded. The concept of laterality has been added, particularly in the Neoplasm and Injury chapters.
AHIMA does not believe that reimbursement considerations should drive code set revisions. However, good specific coded data should be used and can determine and support appropriate reimbursement. The payment computation system, and not the coding system, should define the payment, allowing for cross-service or location data or cost analysis, research, and so forth.
The level of specificity in ICD-10-CM will provide payers, policy makers, and providers with more detailed information for establishing appropriate reimbursement rates, evaluating and improving the quality of patient care, improving efficiencies in healthcare delivery, reducing healthcare costs, and effectively monitoring resource and service utilization. For example, reduced healthcare costs will result if a more specific coding system is employed, facilitating the prevention and identification of fraud and abuse or the specificity needed to conduct good quality improvement and error reduction programs. The exchange of additional data beyond the basic claim, and the time it takes to gather and process such information, will significantly be reduced due to the more specific detail contained in the ICD-10-CM code.
In 1987, AHIMA (then known as the American Medical Record Association) convened a task force to examine issues surrounding the US implementation of ICD-10. Even back then, this task force acknowledged that healthcare information, once synonymous with inpatient hospital statistics, had broadened in definition to encompass the complex requirements of multilevel healthcare programs. We expected that pressures for more and better data would continue to increase to meet the healthcare needs of a changing population, select efficient providers, compare healthcare plans, develop health policy, and monitor provider performance.
A few years later, the NCHS established a Technical Advisory Panel to review the necessity of a clinical modification to ICD-10. An AHIMA representative served on this panel.
In 1997, a draft of the Tabular List of ICD-10-CM and a preliminary crosswalk between ICD-9-CM and ICD-10-CM were made available on the NCHS Web site and public comments were solicited between December 1997 and February 1998. During this comment period, more than 1200 comments were received from 22 individuals and organizations representing a variety of groups, including one governmental agency, two research institutions, three information system developers, four professional organizations, and several healthcare providers. AHIMA submitted extensive comments.
AHIMA supports the adoption of ICD-10-CM as the replacement for ICD-9-CM diagnosis codes. In addition to the significant improvements in specificity and clinical detail in ICD-10-CM, this system allows future expansion to easily accommodate the need for new codes and medical advances, thus ensuring that the system will remain useful well into the future.
In an effort to gather information regarding successful ICD-10 implementation strategies, obstacles encountered during implementation or the transition period, and tangible benefits of ICD-10 adoption, AHIMA surveyed several other countries that have already implemented ICD-10 for morbidity purposes. A number of countries expressed their consternation regarding the failure of the US to have adopted ICD-10-CM by now, noting the detrimental impact on international healthcare data comparability.
In many hospitals around the world, physicians are responsible for assigning diagnosis codes and training programs were developed to ensure proper and consistent use of ICD-10.
Because of the many changes in the organization and structure of ICD-10, many users have found the use of computerized encoders has resulted in improvements in accuracy and efficiency. Users noted that this is largely due to enhancements to the Alphabetic Index, which lend themselves to use in an electronic format.
Unlike the US, many European countries do not have clear national coding guidelines. Reimbursement has not been a significant concern, as most countries maintain national health programs and provide global funding to hospitals. However, hospitals around the world are under the significant pressures of cost containment, shifting resources from inpatient to outpatient surgery, and a realignment of the services they provide. Recent changes in healthcare policies have created new reporting requirements, and national coding guidelines are being implemented along with the implementation of ICD-10.
Like the US, both Australia and Canada developed a modification of ICD-10 for use in their countries (ICD-10-AM and ICD-10-CA, respectively). Parts of Australia implemented ICD-10 for morbidity purposes in 1998 and the rest of the country implemented it in 1999. In Canada, some provinces implemented ICD-10 in 2001, others in 2002, and a few have not yet implemented. To varying degrees, both countries use ICD as the basis for reimbursement formulas. A major impetus behind their decision to adopt ICD-10 was the need for a more up-to-date classification for a more clinically credible case mix system and improved applicability in non-hospital settings. Canada was the first country to move to an entirely electronic product for ICD-10 codes. In other words, there are no paper ICD-10-CA code books available in Canada.
Australia conducted two-day training workshops for experienced coding professionals, using hard-copy books. In Canada, education was provided in three phases. The first phase consisted of a self-learning package that required approximately 21 hours to complete. The second phase consisted of a two-day workshop, which was a hands-on program provided in a computer laboratory. In the third phase, a self-learning package of ten case studies was provided to the coders. All the training programs utilized coding software instead of code books. For new coding professionals, ICD-10-CA was incorporated into academic curricula. Experienced coders in Canada did not find the system all that difficult to learn due to the similarity to concepts in ICD-9. Both countries offered post-implementation “refresher” workshops to coding professionals. Special educational sessions were provided to data users.
The average learning curve was four to six months for coding professionals to feel comfortable with the new coding system. Both countries reported that coding professionals found ICD-10 no more or less difficult to learn than ICD-9.
One significant challenge reported by both countries was a lack of vendor readiness, despite ongoing communication from the start of implementation planning.
Staggered implementations were particularly problematic and a standard nationwide implementation would have been preferable. Earlier and more extensive involvement of information systems vendors would have lessened the delays in software modification.
Benefits realized as a result of implementing ICD-10 include greater detail and specificity, a more clinically credible classification system (resulting in significantly improved data and a system that is easier to use and understand by coding professionals and other users), a much-improved coding system structure and code presentation, and the ability to conduct international comparisons with other countries.
It has been over 20 years since the US converted to a new classification system. Because today's payment systems, as well as many other systems, are based on coded data, there are many more stakeholders, and the range of healthcare settings using ICD-9-CM diagnosis codes has also expanded considerably. It would be unwise to neglect the magnitude of the training issue. However, it is also important to recognize that since ICD-10-CM retains the traditional ICD format and many of the same conventions, it will not be difficult to learn for those users who have been trained in ICD-9-CM diagnosis coding.
Implementation of any new coding system would require new training for coders, clinicians responsible for documentation, and a growing number of data users throughout the healthcare industry. The range of users and settings for which training programs have to be designed and provided is much wider for ICD-10-CM than ICD-10-PCS. As we noted in our April testimony, ICD-10-PCS was designed only to replace ICD-9-CM procedure codes, which are limited in use to the inpatient hospital setting. In contrast, ICD-10-CM is used by all healthcare providers and in all healthcare settings to describe medical conditions and other reasons for healthcare encounters.
Because ICD-10-CM allows greater specificity, clinicians must change behaviors in documentation so the appropriate code can be selected (a goal consistent with the industry’s goals to eliminate medical error). Not only will the codes change for data analysis, a new level of specificity will be available that should also change the level of analysis that can be performed. Both information systems staff and analysts will need to understand the data comparability issues as data between the two systems are compared over time.
The material used for initial preparation and those transitioning skills from ICD-9-CM to ICD-10-CM will need to be revised. Development of ICD-10-CM educational materials must commence as soon as the coding system and regulations are finalized and publicly available. Therefore, it is extremely important for the strategic progression of ICD-10-CM implementation to be determined as early as possible.
The size of the workforce directly engaged in coding has grown, as has the range of coding skill. Today, there are thousands of mastery level coders, signified by the CCS and CCS-P credentials. But workforce shortages and variable skill levels among those responsible for coding in diverse healthcare settings also mean there are many on-the-job trained coders for whom retraining will be more demanding, and coding professionals must understand how to properly use and interpret data derived from both ICD-9-CM and ICD-10-CM diagnosis codes. The greater degree of clinical specificity in ICD-10-CM will require coding professionals to have a better understanding of medical terminology and human anatomy.
Since ICD-10-CM has the same hierarchical structure, the same basic organization, and many of the same conventions as ICD-9-CM, experienced coding professionals will not require the level of extensive training that would be necessary for an entirely new coding system. They will already be familiar with the logical hierarchy and the basic ICD rules. Experienced coding professionals will primarily need to be educated on changes in structure, disease classification, definitions, and guidelines.
For new coders, educational materials will need to be revised and updated to reflect the changes in the coding system and guidelines, but not completely re-written, as the principles of the basic ICD classification will not change dramatically. When considering the timeline for initiation of ICD-10-CM training, it must be recognized that training conducted too early in advance of implementation can adversely impact the effectiveness of the training.
Given the many uses of coded data outlined earlier, multiple categories of users of coded data will require varying levels of training on any new coding system. These categories of users include:
It must be noted (*) that some of these users are already using ICD-10 because of their international work or as otherwise noted in our testimony.
Physicians and clinicians will need to be actively involved in the training process. This will allow them to understand the importance of complete and accurate documentation to support the level of specificity in ICD-10-CM.
Information systems personnel will need to understand the logic and hierarchical structure of ICD-10-CM. Data users will need to understand the definition and composition of categories in the classification.
While the transition poses significant challenges, there are, fortunately, many training vehicles available and appropriate for this effort. Much has changed since the implementation of ICD-9-CM in regards to training, which makes training accessible and affordable. First, the number of publications dedicated to coding training has grown significantly over the past 20 years. These include both books and periodicals. Face-to-face seminars that were widely used to train for ICD-9-CM remain an effective training vehicle, but new technologies offer alternatives possibly superior to traditional face-to-face training. For example, audio seminars can be delivered at low cost to a large audience using the phone, the Internet, or audiotapes and CDs.
Web-based training offers new accessible and flexible training opportunities. Web-based training is an exciting methodology for training masses of people, and can be highly effective in terms of the quality of the education results (for instance, how well participants learn to use the system and apply it in their workplace) and costs.
Again, given the many uses of coded data outlined earlier, multiple categories of users of coded data will require varying levels of training on any new coding system. At present, there are a variety of educational media available and a number of vendors that already provide coding products and services. We anticipate numerous vendors will offer a variety of competitively priced educational programs for ICD-10-CM in formats to suit everyone’s needs and preferred learning style.
Although it would be technically possible for coding professionals to use a paper-based version of ICD-10-CM, given the size and structure of this system, most coding professionals and healthcare organizations will find that this system is easiest to use in electronic format. This view is supported by the experience in Canada, where a decision was made to rely solely on an electronic version of ICD-10. We anticipate that the major encoding software vendors will have ICD-10-CM products available well in advance of system implementation.
AHIMA has a significant history and is committed to the training of the industry in HIM. Education will be made accessible, not only through the Internet but also through our network of 52 component state associations and coding professionals, which have significantly expanded since the implementation of ICD-9-CM. We have built a strong network of coding experts and have expanded our scope and reach through dynamic Internet-based Communities of Practice.
Because the scope of HIM includes coding, we are prepared to address appropriate coding documentation, management (including development and coordination of implementation strategies), and data analysis issues related to this change. Coding leadership, professional development, and coding consistency are central strategic and mission issues for AHIMA, so you can count on our support.
For entry-level and advanced coding programs and for the coding component of HIM academic programs, we anticipate that ICD-10-CM training would be incorporated into the existing ICD coding curricula. We also expect a period of time when students enrolled in coding programs must learn to use both ICD-9-CM and ICD-10-CM diagnosis codes. Eventually, comprehensive education on ICD-9-CM diagnosis coding would be phased out entirely.
In our February 2002 testimony, regarding medical code set standards and HIPAA, and again in our April 2002 testimony regarding adoption of ICD-10-PCS, AHIMA indicated the need for code set standards to include the rules and guidelines for proper use to ensure consistent application and reliable data.
A major strength of ICD-9-CM is that there is an established, organized process, permitting input from a broad range of entities and organizations, for ongoing development of official ICD-9-CM coding guidelines in order to ensure accurate, consistent reporting of coded data throughout the United States. Coding guidelines assist users in coding and reporting in situations where the code set rules, conventions, and definitions do not provide clear direction. These guidelines must be approved by the four organizations known as the Cooperating Parties. Because of the existence of this process, these official coding guidelines were named as part of the ICD-9-CM medical data code set standard. We recommend that this coding guideline development process continue for ICD-10-CM and that these guidelines, as well as the rules and conventions included in ICD-10-CM itself, be named as part of the ICD-10-CM code set standard. It is necessary to include the guidelines as part of the standard to ensure proper and consistent application of ICD-10-CM codes by all users. The integrity of coded data and the ability to turn it into functional information require that all users consistently apply the same official coding rules, conventions, guidelines, and definitions.
The existing official coding guidelines will need to be revised for use with ICD-10-CM. The ICD-10-CM rules and guidelines should be updated on the same schedule as the code set.
The challenges of maintenance are exponentially more complex today than they were when ICD-9-CM was implemented. In February, we indicated that maintenance is also a key issue for any complete and flexible medical coding system. AHIMA has espoused six principles for medical code set maintenance processes, which are:
See Attachment Four for an expanded description of these principles.
These six principles indicate that sound maintenance processes are as important as sound system design, and ICD-10-CM already meets this latter requirement. There should be a unified and logical process encompassing ICD-10-PCS and ICD-10-CM if and when these systems are implemented, and any additional medical code set standards, should they be required.
A major strength of ICD-9-CM is the process for updating the code set, which allows significant opportunity for public input. The ICD-9-CM Coordination and Maintenance Committee meetings are open to the public and comments may be presented orally during the meeting or in writing. The agenda and code proposals are posted on the NCHS Web site, and a notice of the meeting dates, location, and posting of the agenda are published in the Federal Register.
An advisory group comprised of representatives of stakeholders should be established to provide input into the maintenance and guideline development processes. We also recommend that the current Cooperating Party structure be continued, as it has served as a successful process for the development of guidelines that best meet the needs of the major constituent groups.
When we move to a new coding system, a crosswalk should be developed between the old and new systems. It is our understanding that the NCHS plans to develop a crosswalk that will allow both forward and backward mapping.
We recognize that there are significant resource implications of implementing new coding systems. These include:
Both ICD-9-CM and ICD-10-CM will need to be supported in computer system applications for some time. A conversion system will be needed to cross-reference between pre- and post-crossover periods in order to understand the correlation of ICD-9-CM and ICD-10-CM data. As long as ICD-9-CM data are still needed for longitudinal data analysis, retrospective audits, fraud and abuse investigations, payment of claims for services that occurred while ICD-9-CM was in effect, and other activities, users will need to understand both systems.
While, ultimately, healthcare reimbursement, including prospective payment systems, managed care contracts, negotiated rate schedules, and fee schedules, would be recalculated or renegotiated using ICD-10-CM data, we anticipate that, initially, reimbursement rates would not be affected by changing to a new coding system. Rather, we expect that ICD-10-CM codes would be mapped to ICD-9-CM codes. Once sufficient ICD-10-CM data have been collected, reimbursement rates and schedules would be modified to reflect the more specific data.
It is our understanding that ICD-10 is copyrighted by the WHO and that while noncommercial use of ICD-10 is permitted without specific authorization, license fees may be required for use or reproduction of ICD-10 in products that are to be sold. The implications of the WHO copyright, particularly with regard to the impact on the cost to the end users of ICD-10-CM publications or other products, need to be explored and resolved quickly. Canada and Australia reported that their governments paid a license fee to WHO and code book publishers pay royalties based on sales volume.
AHIMA believes that a formal implementation plan encompassing all affected entities, which is established well in advance of the scheduled implementation date within the requirements of HIPAA, is necessary to ensure a successful transition to ICD-10-CM. It is imperative that the NCVHS and the HHS Secretary, with industry consultation, initiate such a plan immediately, given the time constraints required under HIPAA for proposed and final regulations and the various activities we have described above. Delay in such decision-making and commitment could leave the US with a hopelessly outdated system unable to provide the country with meaningful data necessary for all of the purposes mentioned above and an inability to compare global or morbidity and mortality data.
Obviously, it will take some time until the advantages of the improved data produced by ICD-10-CM are fully realized. However, based on the feedback we received from other countries, we anticipate that some of the benefits of the superior data will be appreciated rather quickly, such as within a year or so after implementation. During the transition, the quality of data will undoubtedly suffer, as implementation of any new coding system involves a learning curve. Productivity, by both those reporting the codes and those processing the claims, will undoubtedly be temporarily affected, until proficiency and confidence in using the new system are achieved, resulting in delays in reimbursement and processing of authorizations. Increased claims rejections and denials may be seen for a period of time, due to inaccuracies in code reporting and processing. Data that are confusing and less reliable will result during this transition period when users are still learning to apply and understand the new system. The length of this transition period, and the impact on data quality, will be less for ICD-10-CM than for ICD-10-PCS due to the similarities to ICD-9-CM.
Caution should be used when conducting longitudinal data analysis since diagnoses may be classified differently in the two systems or code definitions may have changed, making it easy to misinterpret data. For example, the time frame for classifying a myocardial infarction to the acute myocardial infarction codes is 4 weeks in ICD-10-CM and 8 weeks in ICD-9-CM. This will result in a decrease in the number of reported acute myocardial infarctions. It will be important for users to understand that this decrease is a reflection of changes in data reporting, not in the actual incidence of myocardial infarctions. It is our understanding that NCHS will conduct a comparability study to assist users of coded data in discriminating between real changes in utilization by diagnosis and those changes that are artifacts of changes to the classification system.
Other classification systems dependent on ICD data, such as case mix and severity of illness systems, will need to be studied to determine the impact of ICD-10-CM in order to ensure accurate data interpretation.
The US needs to move forward as quickly as possible to implement a much-improved diagnosis coding system. Our country needs to fully benefit from the code set enhancements that are necessary for high-quality data, and, ultimately, high-quality patient care. We must also navigate through the HIPAA requirements. Therefore, we believe that final regulations promulgating adoption of ICD-10-CM as the replacement for ICD-9-CM diagnosis codes must be issued in 2003 with implementation to occur no later than 2005.
AHIMA believes that a decision related to ICD-10-CM cannot be made in a void. While we believe the problems associated with the current ICD-9-CM diagnosis coding system warrant immediate attention and leadership, such decision-making must take into account the current and future healthcare environment in the US.
Consideration must be given as to the benefits and drawbacks of implementing ICD-10-PCS and ICD-10-CM at different times versus simultaneously. This is a question that must be addressed in the context of the environment and in order that there are appropriate timetables and strategic planning developed to accommodate the needs of the industry and not just one coding system.
The current implementation process related to HIPAA is often raised as a reason for holding back on the decision to replace the ICD-9-CM diagnosis coding system. True, the transaction and code set implementation is a large undertaking, but we know its parameters and we have learned, perhaps, a better way of setting up a strategic approach to implementation. The current diagnosis coding system is in crisis. As the rest of the world completes implementation of ICD-10, or modifications of ICD-10, delayed implementation in the US will mean a rapidly increasing loss of domestic (between morbidity and mortality data) and international data comparability. We are also delaying realization of the many benefits of using a much-improved coding system. AHIMA does not believe that a decision to implement ICD-10-CM can be delayed until the current HIPAA rules are completely implemented, nor do we believe the healthcare industry can afford to hold off the reimbursement and other considerations that are impacted with any coding system delay.
AHIMA realizes there will be resistance to changing from the status quo, but it must be recognized that while there are costs in implementing a new coding system, there are also costs associated with maintaining the status quo. We are paying a very high price for having delayed this long – and the cost increases. We are already at least a decade behind in implementing new ICD modifications, and like any system maintenance experience, catching up is more costly than staying current. Further delay will not reduce the direct costs. We cannot ignore the indirect costs any longer.
It has been suggested that ICD-9-CM could somehow be “fixed” rather than adopting an entirely new system. We believe that it is not feasible to “fix” ICD-9-CM without severely disrupting the system structure. The advantages of ICD-10-CM cannot be fully realized without adopting ICD-10-CM. It is important to maintain comparability between our mortality and morbidity data, and our death certificates have been coded with ICD-10 for three years now. It is also important to maintain data comparability with the rest of the world, and many other countries have already adopted ICD-10. Implementation of ICD-10-CM would facilitate global research studies.
ICD-10-CM has the capacity to grow as medical science grows, and it could serve our healthcare diagnostic data needs for many, many years to come. We believe that the benefits of the improved data resulting from ICD-10-CM are well worth the costs and difficulty encountered during the transition period. We also believe that we are incurring significant costs by utilizing a hopelessly outdated and limited system and that, ultimately, reductions in costs will be realized as a result of the availability of better data. There would be considerable cost savings realized through more accurate trend and cost analysis using the increased specificity in ICD-10-CM. The increased specificity in ICD-10-CM will result in the availability of better information to support reimbursement (such as justification of medical necessity), which will mean an increased ability of payers to make informed decisions regarding coverage and reimbursement and a reduced need for payers to request medical record documentation to support claims. Better data will:
In summary, AHIMA's position regarding replacement of the ICD-9-CM diagnosis coding system with ICD-10-CM is as follows:
AHIMA and its national network of coding professionals are uniquely capable of assisting in the research on the best implementation strategy. AHIMA’s coding professionals have the training and experience to quickly learn and utilize a new professional coding system and limit the learning curve. AHIMA is also uniquely capable of taking the lead in national workforce retraining and user education for new procedural and diagnosis coding systems.
Finally, Mr. Chairman, AHIMA is pleased to note that we have been asked by Mr. Steven Speil, JD, MPH, senior vice president and chief financial officer of the Federation of American Hospitals (FAH), to indicate to you and the subcommittee, that the FAH has endorsed and recommends the content and approach of our testimony today.
Thank you, Mr. Chairman, members of the Standards and Security Subcommittee, for the opportunity to present our views regarding replacement of ICD-9-CM diagnosis codes with ICD-10-CM, and the environment that must be considered in this decision. AHIMA is deeply committed to working with the Department of Health and Human Services, the NCHS, and other healthcare industry groups to advance coding practice and improve our nation's healthcare data through adoption of new code set standards. Today, I am accompanied by Linda Kloss, AHIMA’s chief executive officer and Dan Rode, AHIMA’s vice president for policy and government relations, and we are prepared to answer any questions or concerns the subcommittee might have at this moment, during these two days of testimony, or in the future.
| Sue Prophet, RHIA, CCS Director, Coding Policy and Compliance AHIMA 233 North Michigan Avenue Suite 2150 Suite 409 Chicago, IL 60601 |
Dan Rode, MBA, FHFMA Vice President, Policy and Government Relations AHIMA 1730 M Street, NW Washington, DC 20036 |
| Telephone: (312) 233-1100 ext 1115
E-mail: sue.prophet@ahima.org |
Telephone: (202) 659-9440 E-mail: dan.rode@ahima.org |
ICD10CMtest-052902fin
AHIMA believes the collection of accurate and complete coded data is critical to healthcare delivery, research and analysis, reimbursement, and policymaking. The integrity of coded data and the ability to turn it into functional information requires that all users consistently apply the same official coding rules, conventions, guidelines, and definitions (the basis of coding standards). Use of uniform coding standards reduces administrative costs, enhances data quality and integrity, and improves decision-making – all leading to quality healthcare delivery and information.
For the United States to have and maintain quality data and information, coding standards must be required and promoted for uniform application and use, and not violated to meet parochial or short term requirements. In order for the nation to obtain, store, and utilize quality information, coding standards must be uniformly applied across sites of service and developed and maintained to meet the national and international needs of healthcare delivery, research, policy making, and the interpretation of healthcare data for the benefit of humankind. AHIMA’s coding professionals are educated and certified to ethically apply and utilize national uniform coding standards to support these data quality, analysis, and maintenance functions.
Coded clinical data are used by healthcare providers, payers, researchers, government agencies, and others for:
The coding of clinical diagnostic and procedure data involves the translation of clinical information collected during healthcare encounters into diagnostic and procedural codes that accurately reflect the patients’ medical conditions and services provided. A medical code set is an established system for encoding specific data elements pertaining to the provision of healthcare services, such as medical conditions, signs and symptoms, diagnostic, and therapeutic procedures, devices, and supplies. A code set includes the codes and code descriptions and, potentially, the rules, conventions, and guidelines for proper use of the codes.
Today, many coding practices are driven by health plan or payer reimbursement contracts or policies requiring providers to add, modify, or omit selected medical codes to reflect the plan or payer’s coverages, policies or government regulations, contrary to standards for proper use of the code sets. Payers do not uniformly abide by such standards for proper application of the medical code sets. Code sets are not revised on the same date, and often payers require the continued use of deleted or invalid codes. Individual health plans, and even different contractors for the same plan (including Medicare and other government contractors), develop their own rules and definitions for the reporting of a given codes. These variable requirements, which affect all the medical code sets currently required for reimbursement claims submission to third-party payers, undermine the integrity and comparability of healthcare data.
New uses of healthcare data are constantly evolving, further demanding that careful attention be paid to accurate and consistent application and reporting of coded data. Code sets must be sufficiently flexible to meet these changing needs, while maintaining stability and continuity over time to ensure data comparability. Those responsible for coding clinical data must be educated and trained to apply coding standards correctly and uniformly. The current situation, resulting in inconsistent coding practices, leads to potentially bad healthcare decisions today, and in the future.
The American Health Information Management Association is a dynamic organization of more than 41,000 specially educated professionals – all working to ensure accurate and timely information within healthcare.
up-dated & approved 5/18/2002
The American Health Information Management Association’s 40,000-plus members manage patient information in the form of health records and databases in provider, health plan, government, research, and other private organizations, facilities, and practices. The responsibilities of these members include coding, and our most recent membership survey data shows that 50 percent of AHIMA’s active members cite coding as one of their primary job functions, whether they manage coding functions, are a coding professional, or at as a consultant.
The responsibility of health information management (HIM) professionals for coding dates back to the 1930s when the use of the new Standardized Nomenclature of Disease was being promulgated, and Dr. H. B. Logie, executive secretary of the National Conference on Nomenclature of Disease, asked our members to take on this role.
AHIMA’s HIM credentials denote entry-level competency in multiple aspects of health information practice, including coding. The educational curriculum for HIM professionals at the baccalaureate and master’s level includes nomenclature and classification systems, management of healthcare coding, and derivative systems. Health information technicians with an associate’s degree learn to code with ICD, CPT, and specialty code sets. Thus, the entry-level credentials of our field — the registered health information administrator (RHIA) and the registered health information technician (RHIT) — denote academic preparation in coding and classification systems. In addition to the RHIA and RHIT credentials, AHIMA also offers several specialized coding certifications: certified coding associate (CCA), certified coding specialist (CCS), and certified coding specialist–physician-based (CCS-P). The RHIA and RHIT credentials denote entry-level competency in multiple aspects of health information practice, including coding, whereas the CCA credential denotes entry-level competency in coding alone. The CCS and CCS-P are the marks of highest clinical coding mastery in the industry, gained through experience or additional education beyond basic competency. The specialized coding certifications – CCA, CCS, and CCS-P – do not require academic preparation.
AHIMA members work in a variety of healthcare industry sectors and in a variety of positions. In the course of their work, they use most of the standardized coding systems we will discuss today, and others, not only in conjunction with the HIPAA transaction sets, but also for a variety of information, system, and data tasks of significant importance to the patients represented in the data, the coder’s employer, and the general public directly and through public and private bodies nationally and internationally.
To be designated as a HIPAA standard, each standard should:
Like the retraining issue, the challenges of maintenance are exponentially more complex today than 20 years ago. Yet our process is not fit for the pace of change or the needs of our stakeholders. As we examine how and when to implement new code sets, we must commit ourselves to modernizing the process for their maintenance.
AHIMA believes the following six principles should guide code set maintenance in the future: