Re: Medical/Clinical Coding and Classification Issues regarding the Health Insurance Portability & Accountability Act of 1996 (P.L. No. 104-191)
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. My name is Nelly Leon- Chisen. I am the Director of the Central Office on ICD-9-CM at the American Hospital Association (AHA). The 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 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: the Health Care Financing Administration (HCFA), the National Center for Health Statistics (NCHS) and the American Health Information Management Association (AHIMA). The need for standardization of clinical codes is extremely important to our members, particularly as they relate to transactions identified in the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
Increasingly, diverse reporting requirements for clinical codes, as imposed by payers and others, have burdened our members. Wide variations in coding have not only increased our member's costs, but what is more important, they have compromised the primary purpose of clinical codes-- to provide an accurate record of what happened to the patient. When providers are forced to code events differently for different payers, it becomes confusing, and ultimately compromises the integrity of medical data . For this reason, AHA is very supportive of the committee's efforts. Before I respond to the specifics of each question, I would like to give you a summary of what we would like to see take place.
The importance of accurately reporting clinical codes cannot be overstressed. Our members rely on clinical codes because they are a key data component used for bench marking, quality assessment, research, public health reporting, and strategic planning. To achieve these objectives requires accurate and comparable data. These goals were always important to providers, but are even more critical now as many individual providers are moving to integrate services across settings. Standardizing the "language" they use to communicate will greatly enhance their ability to deliver high quality, well-coordinated care. We cannot achieve this unless we have uniformity and standardization of clinical data reporting requirements.
By building on the strengths of the existing infrastructure--namely the ICD-9-CM and the CPT-4, and by making some simple changes in the use of these coding classifications, our nation can make substantial progress toward the administrative simplification goals outlined in HIPAA.
Many questions outlined talk about the use and development of ICD-9-CM and CPT-4 and how it has affected users. Other questions ask whether the process of code development belongs in the public or private domain. Each has advantages and disadvantages, however, for our members, the important issue is whether the code development process incorporates the following principles:
Complementing these principles is a well-defined maintenance and implementation process. Input into the process should be broad-based and changes to the coding system should take into consideration the needs of all users. Overall, the process should also be predictable and take into account the capabilities of the users to adapt to coding changes when they occur. Providers should be able to count on routinely scheduled meetings to review coding changes and a certain date for when approved coding changes take effect.
In the transition to national standards, it is imperative that the following requirements be adopted:
1. What medical/clinical codes and classifications do you use in administrative transactions now? What do you perceive as the main strengths and weaknesses of current methods for coding and classification of encounter and/or enrollment data?
For inpatient services our members use ICD-9-CM for reporting diagnoses and procedures. For ambulatory claims, ICD-9-CM is used to report the diagnosis while reporting for procedures is more varied. For instance, Medicare requires CPT-4, State Medicaid varies, Blue Cross/Blue Shield typically uses ICD-9-CM, commercial payers use either ICD-9-CM or CPT-4. Many of our members also use ICD-9-CM procedure codes for ambulatory transactions in order to be able to cross-analyze and compare inpatient data with ambulatory data. To further complicate the situation, Medicare transactions often use HCPCS level II (national) and level III (local) codes. It should be noted that Level III (local codes) requirements vary from state to state causing even further complications and burdens for providers.
Each coding classification system has strengths and weaknesses:
Strengths of ICD-9-CM:
Weaknesses of ICD-9-CM
Strengths of CPT-4
Weaknesses of CPT-4
Building on the existing coding infrastructure used by Medicare (ICD-9-CM for inpatient and combination of ICD-9-CM and CPT-4 for ambulatory transactions) will strengthen coding uniformity.
2. What medical/clinical codes and classifications do you recommend as initial standards for administrative transactions, given the time frames in the HIPAA? What specific suggestions would you like to see implemented regarding coding and classification?
For the near term we recommend maintaining the existing classification systems, namely ICD-9-CM for inpatient transactions (this includes both diagnosis and procedure coding); and ICD-9-CM diagnosis coding in combination with CPT-4 procedural coding for ambulatory transactions. Again, building on the existing coding infrastructure used by Medicare will strengthen coding uniformity.
For the longer term, developing a single classification system that can be used for both inpatient and ambulatory settings could lessen the administrative burden to maintain dual systems for health care facilities. However, a new single system should not be adopted without a thorough evaluation of its utility for different types of users and a determination that the benefits of the new system outweigh the cost of the transition.
Regardless of the classification systems selected, it is important that health care providers have clear, unambiguous instructions, and consistent coding and reporting guidelines that are readily available and widely accepted by all payers. This allows for the development of comparable health information which will provide a better basis for establishing an equitable payment system. Any new system must undergo a thorough testing for compatibility to the DRG system, ASC rates, and other ambulatory payment systems like APGs or simple fee schedules, to prove their value and importance. The new system must also demonstrate its ability to provide an accurate record of the patient's condition and what happened to the patient before and after the rendering of care.
3. Prior to the passage of HIPAA, the National Center for Health Statistics initiated development of a clinical modification of ICD-10 (ICD-10-CM), and the Health Care Financing Administration undertook development of a new procedure coding system for inpatient procedures (called ICD-10-PCS), with a plan to implement them simultaneously in the year 2000. On the pre-HIPAA schedule, they will be released to the field for evaluation and testing by 1998. If some version of ICD is to be used for administrative transactions, do you think it should be ICD-9-CM or ICD-10-CM and ICD-10-PCS, assuming that field evaluations are generally positive?
AHA has worked closely with our institutional members who are field testing the ICD-10- PCS during year two of its development process. Thus far, the field testing of ICD-10- PCS is positive. Unlike ICD-9-CM, ICD-10-PCS seems to allow for the easy expansion of new procedures codes. The system holds a great deal of promise and should be considered for future use, pending development completion, and evaluation of final results of testing. However, we believe that before implementation takes place, the system should be tested in all settings. Equally important for successful implementation is the establishment of a carefully planned and predictable schedule so that all healthcare participants move in unison.
4. Recognizing that the goal of P.L. 104-191 is administrative simplification, how, from your perspective, would you deal with the current coding environment to improve simplification, reduce administrative burden, but also obtain medically meaningful information?
A critical step is to include a requirement to have all payers abide by the same national coding guidelines as published through official sources and that all code changes should follow the same effective date no matter the system used. Currently the AHA publishes Coding Clinic for ICD-9-CM in cooperation with the American Health Information Management Association, the National Center for Health Statistics and the Health Care Financing Administration. Medicare and many private insurers have accepted the advice published in Coding Clinic. Other insurers do not accept this publication and instead have developed their own rules that may differ from nationally established practices. Consequently, this causes a significant burden for our members since different payer rules need to be maintained, followed, and applied for each insurer.
A further step to ensure uniformity is to eliminate local HCPCS Level III codes as developed by individual states to handle local Medicare carrier requirements and Medicaid. As we mentioned earlier, these codes vary from state to state and cause significant administrative burdens for our members who often provide services across state boundaries. Requiring the use of acceptable national instructions is the important first step.
Finally, it is critical that our nation establish a predictable way to manage coding system changes. Currently, annual code changes for ICD-9-CM are effective the first of October. Several years ago the AHA sought changes in the way HCFA issued updates to HCPCS. Consequently, we now have HCPCS Level I (CPT-4) and Level II (national code) changes introduced each year on January first. The HCPCS level III codes are introduced anytime throughout the year. Medical personnel responsible for handling codes need this predictability to properly train staff and make the necessary changes to their information systems. Introducing changes at different intervals makes it difficult not only to coordinate the changes within the organization, but also to be able to effectively process the exchange of this information to outside parties. Another important area that suffers is the study of data being submitted, particularly when code changes are not done simultaneously.
5. How should the ongoing maintenance of medical/clinical code sets and the responsibility for intellectual input and funding for maintenance be addressed for the classification systems included in the standards? What are the arguments for having these systems in the public domain versus in the private sector, with or without copyright?
Classification systems, whether in the public domain or in the private sector, with or without a copyright, should meet several goals. They should:
While it would seem that these goals might be easier to reach if classification systems were in the public domain, the American Hospital Association would not want to preclude private sector or copyrighted systems. The private sector has played a key role in the past in developing these systems and sometimes the availability of a copyright is an important incentive to encourage useful developments.
One model that the AHA has supported that meets the above-stated goals is the maintenance process for the ICD-9-CM codes through the ICD-9-CM Coordination and Maintenance (C&M) Committee process. The C&M accepts opinion from the users of the system, widely publicizes any proposed changes and accepts public comment. Our role, is to help identify key issues for discussion as brought forward by our members through Coding Clinic's Editorial Advisory Board. The C&M considers the comments of all users and issues recommendations.
6. What would be the resource implications of changing from the coding and classification systems that you currently are using in administrative transactions to other systems? How do you weigh the costs and benefits of making such changes?
Every health provider is affected by any type of change to the coding system. The real question is: To what extent and to what degree? The bulk of the cost of managing changes are those associated with training personnel so they are educated and can develop a high level of proficiency in the routine use of the coding system. You should also note that small and rural health care providers may not have available to them the information systems and coding system support programs that would allow them to work with computer encoding. A major change to the existing coding system nomenclature would require extensive and costly modifications to existing health care information systems and training of support staff. Our members have said they do not want a costly conversion to another standard unless it can clearly prove that it is better than the one they are currently using. A better system is one that is not just marginally better, but, one that is much better. The system must be tested in all care settings. The evaluation of benefits must also include ease of use, efficiency, uniformity and data integrity. Movement to any new system must be carefully planned and predictable. To achieve uniformity and minimize the burden, all payers must participate.
7. A Coding and Classification Implementation Team has been established within the Department of Health and Human Services to address the requirements of P.L. 104-191; the Team's charge is enclosed. Does your organization have any concerns about the process being undertaken by the Department to carry out the requirements of the law in regard to coding and classification issues? If so, what are those concerns and what suggestions do you have for improvements?
Overall, we do not have any concerns about the process being undertaken by the Department. We are confident that the team will see the value of maintaining coding uniformity and will consider the needs of the coding users. The AHA and its members appreciate the opportunity to provide comments on the use of classification systems.
Again, thank you for the opportunity to provide comments to you, I will be happy to answer any questions you may have.