Presented by:
Nelly Leon-Chisen, RHIA
Director, Coding and Classification
American Hospital Association
Chicago, IL 60606
My name is Nelly Leon-Chisen, director of coding and classification at the American Hospital Association (AHA). On behalf of our nearly 5,000 member hospitals, health systems, networks, and other providers of care, I would like to thank you for the opportunity to comment on the possible future implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
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. The Office is also the publisher of Coding Clinic for ICD-9-CM, 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 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 perform case selection for studying “best practices” in disease management by using the ICD-9-CM diagnosis codes. Hospitals can use coded data to identify the most prevalent diagnoses in their community and determine what services are most needed to provide the best care to their patients.
ICD-9-CM has been in use for more than 20 years and an update is long overdue. Over time we have seen a shift in the way we deliver care from inpatient acute care to outpatient, home care, long-term care and other settings. The ability to incorporate new codes or expand enumeration to accommodate change has been limited because of physical numbering constraints. While the numerical constraints are not as binding as in the procedure section, ICD-9-CM diagnostic codes are nevertheless outdated and in many instances insufficient to provide detail for non-acute conditions. Some categories provide vague and imprecise diagnosis codes.
Hospitals have been aware for many years that ICD-9-CM was becoming outdated and would need replacement and have been ready to accept a change to ICD-10-CM. We agree with the NCVHS’s statement in their 1993 report:
Because the International Classification of Diseases, 9th Revision (ICD-9) is rapidly becoming outdated and worldwide support and maintenance of the classification will terminate, and because the International Classification of Diseases, 10th Revision (ICD-10) represents significant improvements in coding primary care encounters, external causes of injury, mental disorders, and neoplasms, we have recommended that the Department immediately commit resources to assess the applicability of the ICD-10 for coding morbidity; to identify problem areas and make modifications, as necessary; and to develop implementation plans.
The AHA believes that this statement made by NCVHS, nearly 10 years ago, still holds true. Since then, ICD-10 has been reviewed and critiqued in the United States by hospitals, coders, medical specialty societies and researchers. Areas for improvement have been identified and modifications made. The final and complete last remaining portion of the 1993 NCVHS recommendation is recommendation remains the development of implementation plans. The AHA continues to support the 1993 NCVHS recommendation and supports the migration to ICD-10-CM.
ICD-10-CM is more comprehensive than ICD-9-CM and equates more closely with the vocabulary and practice of current medicine. This enables more detailed and accurate classification of diseases, which leads to more efficient and effective data retrieval. Improvements in the ICD-10-CM content include more detailed information on ambulatory and other sub- and non-acute care encounters, expanded injury codes, combination diagnosis/symptom codes which would reduce the number of codes needed to fully describe a condition, laterality, and a more consistent method of coding post-procedural conditions. In addition, ICD-10-CM allows the capture of information of risk factors to health such as lifestyle, life management, psychosocial circumstances, and the occupational or physical environment.
More detailed code assignments, made possible by ICD-10-CM, are needed. They would greatly reduce administrative burden for hospitals. More detailed codes would:
I will now address issues related to the implementation of ICD-10-CM such as the timing, cost, and testing needed. Many of these issues are similar to the issues we raised in previous testimony to this subcommittee related to the implementation of ICD-10-PCS. These are issues that would need to be considered in changing ANY clinical coding system. —whether a diagnosis or procedure coding system, whether from ICD-9-CM diagnosis to ICD-10-CM diagnosis coding, whether from ICD-9-CM procedure coding to ICD-10-PCS, or from ICD-9-CM procedure coding to CPT coding for the hospital inpatient environment.
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‘s (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-CM implementation for diagnosis coding be carried out in tandem with the migration to the ICD-10-PCS procedure codes. The AHA also supports their recommendation to implement ICD-10 three years after implementation of the HIPAA electronic transaction standards.
“Lessons learned” from the international implementation of ICD-10 diagnosis coding have shown that it has taken two years, at a minimum, to implement the system. In the United States, there is a greater level of automation and a more pervasive use of clinical coding across different health care delivery systems than in the rest of the world. An additional year would be beneficial to ensure that thorough testing of the information systems and the electronic transactions utilizing the codes takes place.
Accurate coding translates to accurate reimbursement for our members. A disruption of the “language” used to report what was wrong with the patient and what was done for the patient, could have serious financial implications for our hospitals if the submission and payment of electronic claims was hampered.
Implementation of ICD-10 (both diagnosis and procedure coding) 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-CM.
For hospitals, the bulk of the cost associated with the adoption of a new 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. The costs of appropriate training could be quite high for hospitals. However, the basic principles underlying ICD-10-CM are similar enough to ICD-9-CM that experienced coders should be able to quickly learn the new system. In reviewing a draft version of the ICD-10-CM codes, experienced coders were able to follow the draft and identify how the new codes worked or fit in with the existing ICD-9-CM diagnosis codes.
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, claims submission, groupers, advanced beneficiary notices (ABN) systems, medical review systems, and other financial functions. In essence, every electronic transaction requiring an ICD-9-CM diagnosis 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-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.
ICD-10-CM has not been thoroughly tested in the United States. However, the WHO version of ICD-10 as well as two different clinical modification versions (Australian and Canadian), have already been implemented into real-life applications. Successful implementations have taken place from Western European countries with sophisticated information technology, progressive health care delivery systems similar to the U.S., and experienced coders, to countries with minimal automation, health care delivery systems where only minimal basic services are provided and new or inexperienced coders. America’s hospitals are willing and ready to take on the challenge of implementing ICD-10-CM. The countries that have implemented ICD-10 have used it for a variety of functions—from management of utilization resources, to clinical management, research and reimbursement. ICD-10 has even been implemented internationally in Diagnosis Related Groups (DRG) or DRG-like systems—some for payment and others for clinical management purposes.
Our review of the ICD-10-CM draft in 1998 found that the changes made to ICD-10-CM are logical, coder-friendly and an improvement over ICD-9-CM. The greater detail in specifying conditions and the expansion to unique codes for conditions that were previously delegated to a catch-all “other specified” category, will make for more specific data collection. Many previously confusing areas have also been corrected with the greater level of detail. Our review was performed from the stand point of evaluating whether the system would be capable of answering the types of questions that a hospital coder would have or the types of questions often submitted to the Central Office clearinghouse by ICD-9-CM users. Additional testing is needed to ensure that the alphabetical index is as useful and complete as possible. We would welcome the opportunity for the AHA to work with our members to conduct further testing including medical records review across different health care settings.
Additionally, the testing should also consider the compatibility of the new system with current payment systems including prospective payment systems. The AHA supports the change to ICD-10 based on the assumption that the use of ICD-10-CM will not result in lower reimbursement to providers compared to levels they would receive by using ICD-9-CM.
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.