Subcommittee members, invited guests, and speakers, it is a pleasure to be here today to discuss standards for coding and classification systems. My name is Meryl Bloomrosen and I am the Vice President of Health Information Services for Aspen Systems Corporation. Aspen is an employee-owned information management and technical consulting services firm based in Rockville, Maryland.
For over 30 years, Aspen has provided services to clients in both the public and private sectors. We have had the opportunity and the privilege to participate in numerous projects dealing specifically with coding and classification systems for healthcare providers, health data organizations, and state and federal government agencies. My remarks today are based on the collective knowledge and experience of our health information staff who share your enthusiasm and concerns about the standardization of coding and classification systems. I also offer you the viewpoint of a professional who has herself worked in the industry as a healthcare administrator, a health policy analyst, and a coding and data quality consultant.
Aspen has worked with hundreds of healthcare provider organizations and we have reviewed thousands of clinical records across provider settings (hospitals; HMOs; physician practices; clinics and nursing homes). We have considerable experience helping our clients implement, understand, and respond to mandatory data reporting requirements. We have also conducted numerous workshops and training sessions on coding, clinical documentation, and information systems implementation for a diverse group of healthcare providers and health data organizations. Over the years we have traveled throughout the United States and reviewed thousands and thousands of records for clinical, financial and research oriented projects. On behalf of our many federal and state agency clients, we have ourselves had the opportunity to collect, merge, analyze extensive data sets and then publicly disseminate information on various health and health-related topics.
We are very familiar with the overlapping needs of health data. While the administrative simplification we are focused on during these hearings revolves around those data sets needed for administrative transactions, surely we all accept the fact that these data are routinely used for ever increasing number of other purposes. Providers need data in order to treat their patients and to choose among treatment modalities; payers require data to verify eligibility for treatment and to determine medical necessity for care; researchers need data for their many outcomes measurement projects; regulators and policy makers obviously require data to make prudent and cost effective decisions that will ensure the public health and well being of our country's and the rest of the world's citizens.
We have reviewed the questions that face the Committee. Our remarks are organized to follow the Committee's specific questions and conclude with general comments that we offer for your consideration. We are pleased to share our views with you during your hearings and would be happy to provide additional assistance as you proceed to finalize your recommendations:
Question 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?
As I mentioned earlier, Aspen works directly with providers in their efforts to report data to state and federal health programs, submit financial data for payment, and implement clinical information systems throughout their delivery system(s). Thus, our involvement with coding and classification systems includes the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), the Physician's Current Procedural Terminology (CPT), 4th Edition, the Health Care Financing Administration's Current Procedural Coding System (HCPCS), Diagnosis Related Groups (DRGs), and Ambulatory Patient Groups (APGs).
Some strengths of the current coding and classification systems include their widespread use and acceptance, and the structured nature already in place for the maintenance of these systems. The systems have been around a long time and, generally speaking, the user community knows when to use which code system. This familiarity should not be taken for granted. The complexity of updating any coding system from the users' perspective is vital to their understanding of and ability to use the system itself.
Data systems have been set up to recognize and accept these codes. In general, users know when to report which codes and where to go for technical assistance regarding coding decisions. Systems, processes, and procedures are already in place for the certification and continued checking of credentials of coders using these systems. Mechanisms have been established and refined over the years to address code interpretation, implementation, and updates.
Nonetheless, there are perceived and real weaknesses and challenges inherent in all these systems and in the established mechanisms for their updates and revisions. These include their limitations in keeping up-to-date with new and changing medical technology and devices and treatments. While the codes themselves can be blamed for their failure to reflect the most current technology or treatment modality, one can also look to the fact that there has to be some control over the proliferation of codes to respond to every special interest group's needs or perceived needs. Thus, the timelines and the timing of adding or revising codes to reflect current medical practices is crucial for all code systems.
Other challenges include the need for each system to reflect the ever-increasing diversity of care provided by many different types of practitioners across an ever-expanding variety of provider settings and their inability to do so. Other issues relate to structural and taxonomic limitations of some of the systems due to compression problems making the addition of new and revised codes difficult. There is also well known incongruence between existing procedure coding systems.
Additionally, there is a lack of uniformity in reporting requirements and code acceptance across data-collecting entities. Data reporting instructions are often shadowed by whether a treatment or diagnosis is covered by a health plan or program. This in turn influences whether codes are established for a particular treatment or diagnosis and when codes do exist, whether they are accepted when reported. The Committee, therefore should explore what additional efforts are necessary to establish definitive limitations on variations of codes, code rules, interpretations of guidelines, and reporting mandates. The healthcare industry cannot simply do "business as usual" when it comes to coding.
Finally, the burgeoning health care industry and its ever-increasing reliance on coded data as drivers of decisions makes the timely distribution of new code information, code application and interpretation, and code changes the keystone of the entire infra-structure. These last issues will remain with us and therefore are extremely critical no matter which coding or classification system or systems are used.
Question 2 - What medical/clinical codes and classifications do you recommend as initial standards for administrative transactions, given the time frame in the HIPAA? What specific suggestions would you like to see implemented regarding coding and classification?
Aspen suggests that the answer to this question is largely driven by the time constraints faced by the Committee and the coding community. Thus, we would suggest initially that ICD-9-CM and HCPCS be retained as the standard for administrative transactions. As someone who participated in theconversion of ICD-8 to ICD-9-CM, I urge the Committee to be modest in its recommendations, given the time frame constraints. Aspen suggests no matter what systems are endorsed, a strong public/private partnership is necessary to successfully comply with HIPAA as it relates to administrative simplification and standardizing coding and classification systems.
Consider just the number of federal and state health programs and their related information systems and the multitude of healthcare information systems, including encoders and Groupers, used to report health data to the Department, all of which are driven by these codes that would have to be revised or reprogrammed to accommodate significant changes. Existing federal payment systems using DRGs, APGs (based on currently used ICD-9-CM and CPT) and the like would also need modification based on any new coding system.
The need for a smooth, even seamless transition from any of the currently used coding systems to new ones cannot be understated. The significant undertaking required to assure a transition that would be transparent to the coding community, or at least not bring the industry to a grinding halt, will be immense. Thus, we believe that the Committee should consider both short and long term recommendations regarding coding and classification systems. There may not be a unanimous agreement among those involved with coding on the ideal system. However, I would suggest that most of us would agree that in order to meet the deadlines facing the Department, a prudent approach is required at this time.
An obviously conservative and yet practical decision would be to move forward with the endorsement of existing systems (ICD-9-CM and CPT 4) for the near/immediate term. In the meantime, in order to meet future industry needs, efforts can and should proceed to either enhance the existing systems so that their deficiencies are addressed, or move to one or more new coding systems assuming that they too do not suffer from any serious deficiencies. This is not a novel ideal; as we all know there are several efforts to revise or overhaul existing systems, although they are in various stages of development. A transition to any new system will require a focused schedule so that all aspects of transition and data systems conversion are planned for. New system implementation would need to have minimal impact on both providers and their patients in terms of their ability to deliver and receive care.
We recognize that the Committee is dedicated to a successful implementation of administrative simplification. Thus, the logistics required to implement change within both the pubic and private sectors must also be a critical priority in its thinking. Given the extremely short timeframe within which the Committee is working, it seems challenging, to say the least to consider adoption of any new system in the immediate future. In fact, it seems extremely optimistic that such a transition could successfully address all the facets of federal and state program modifications, automated systems conversions, cross walks between codes, and training of all practitioners, coders and code users.
Our experience with major transitions of this sort is that the ability of the industry to respond to any new mandate will be, in part, influenced by what they understand regarding what is required of them. For those of us who lived through the conversion in this country from ICD-8 to ICD-9-CM, we know it can be done, but we also know that it required an extensive and cohesive public and private sector partnership. The transition plans were strategically comprehensive and included a remarkably well orchestrated series of "train the trainer" teaching workshops.
Back in those days, of course we were not yet concerned about coding for payment; DRGs, APGs, risk adjustment, performance measurement and the like. Today, there are considerably more people involved in coding and coding decisions. The sheer magnitude and complexity of training the industry must be considered as a key priority in a movement to any new system or enhancement of a current system. Widespread industry notification and comprehensive communication programs will also be necessary to be absolutely sure that the "message" reaches everyone throughout the industry. The Committee should also be concerned with possible industry skepticism about any new system and likely confusion surrounding its implementation. To the extent that the industry can be assured of limited risk and be provided with a sense of stability in converting to any new system, the transition will be more successful.
Question 3 - Prior to the passage of HIPAA, the National Center for Health Statistics initiated the 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?
The ongoing efforts of the NCHS and HCFA in their coding systems work are significant factors for your consideration. Discussions about and efforts to implement ICD-10 and ICD-10-PCS are certainly key to your deliberations. We certainly support a rigorous field testing and evaluation of any proposed systems. Such testing should include as many different providers across as many of the applicable settings as appropriate.
However, we suggest that "generally positive" field evaluations may not be the desired goal of the testing. We would hope that a more definitive industry acceptance would be achieved/measurable before the migration to the new system(s).
Why can't the testing include an assessment of the comparative performance of both new and current systems against a set of measurable and perhaps weighted criteria in much the same way the researchers have scrutinized the various case-mix measurement and severity adjustment systems over the years? Do we know how the various new systems can and will perform in inpatient and outpatient settings? in hospitals? ambulatory care clinics? physician office settings? under fee-for-service and managed care scenarios? for all types of practitioners, including physicians, nurses, therapists etc.? Have or can the systems be tested and evaluated as to how they might affect morbidity and mortality statistics so that our national trend data aren't greatly skewed? What precautions can we take to mitigate the inappropriate interpretation of data coded and reported according to a new system? Will the new system(s) perform well for billing and reimbursement? outcomes and performance measurements? public health reporting? What performance tradeoffs are we willing to accept from our coding and classification systems?
Since no system is likely to be seen as ideal for everyone, it seems that the solution should address most of the needs of as many users as possible. If the industry field testing demonstrates "problems" with one or more aspects of a given system, will there be sufficient time to address the problems prior to implementation by the year 2000? Will the field testing allow for system vendors to incorporate the new codes into their products? Will research need to be conducted regarding the effects of any particular system on DRGs? or APG assignment? on RVUs?
We will also need to cross check systems to determine variations in payments and outcomes measurements when moving from one system to another. Will crosswalks or conversion tables be provided to the industry? by whom? Will there be sufficient time to develop and deploy comprehensive training materials and programs across the industry? Are we assured that these proposed systems will be open ended to account for new technologies and devices; new treatments and treatment modalities?
Again, we strongly urge the Committee and others to carefully consider the training, transition, and systems conversion logistics and costs when assessing the timeline for implementation. Further, we want to be sure to note that any transitions occurring in the next three years will be facing us while we are contending with the year 2000 challenge for software conversion alone.
We again wish to emphasize that advanced methods for information dissemination and training are key issues in the Committee's decisions regardless of the coding system. Coders' and practitioners' awareness of impending changes are essential ingredients to the successful implementation and field deployment of any code system. Once a decision is made to change, the industry must move expeditiously to ensure rapid and widespread information dissemination of the decision to change, what the change is, the timetable for implementation, and where to go for more information. The need for real-time information about coding in general, code-specific information, and application of coding rules and guidelines is also critical. Let us not forget that the practitioners themselves, and not just the coders, must be brought into the information loop so that their documentation is adequate to support "correct" coding no matter which system is in use. And further, data organizations must all be required to convert to the new system simultaneously so that providers do not face submitting data to one payor using the new codes while reporting other data to another payor using the old codes. To do otherwise would not be administrative simplification-- this would be a nightmare.
Aspen believes that it will take at least until the year 2000 and probably beyond "to do it right" ---for all necessary procedures, computer systems, and mechanisms-- to be in place to correctly and uniformly implement a new or revised coding system. We of course assume that the implementation date (effective release date) for any system will allow the industry sufficient time for training and systems conversion. However, we would support a decision that eliminates the frustrations the industry would face if it were to experience multiple conversions in a short time period. How well the industry can comply with a mandate for change will in a large part be influenced by how well we plan for that change.
Question 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?
Aspen recognizes that attempts have been ongoing for decades to simplify health data reporting, and includes such activities as the establishment of uniform and minimum data sets, the adoption of standard forms such as the UB-92, and the use of specific code systems within payment methodologies. In some respects the tools are already in place to allow for administrative simplification. One of the missing links involves the interpretation of existing guidelines, mandates, and uniform practices. We believe that as you consider various coding systems options, you must be sure that the selected system(s) will serve the industry's long term needs and interests as well as satisfy short term deadline requirements.
Thus, an area that deserves attention is the additional efforts that might be warranted to assure the correct application and acceptance of codes contained in ICD-9-CM and/or HCPCS. For instance, our experience tells us that even published official coding rules and guidelines are often subjected to payor-specific interpretation. We continue to see guidelines and/or rules regarding code acceptance that have no clinical basis, but are rather coverage-related or computer system related. In our consulting practice, it is not uncommon for us to hear about how decisions regarding what data to report are influenced by whether the claims processing entity or the payor will accept a given code or not. We have also heard about extensive delays in acceptance of codes when updates are made, such as in January or October of each year when CPT and ICD changes go into effect. We know that there are state agencies and private sector organizations who either cannot or will not accept the most current codes due to delays in computer system updates. These are not problems unique to any specific code system nor do we believe that these are deficiencies in the codes. These are problems relating to variation in the enforcement of data reporting standards that already exist.
At a time of changing public health needs and priorities, the Committee and the Department can make important strides in taking on the very serious issues related to coding and code use. The decisions about which code system or systems to recommend will have significant implications for many years to come. The opportunity to establish a refined, systematic and uniform approach to coded data so as to assure its quality, widespread acceptance and applicability across our diverse healthcare system should not be overshadowed by overzealous efforts to do too much too soon or too quickly.
Question 5 - How should the ongoing maintenance of medical/clinical code sets and the responsibility, 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?
As an information management company and information provider ourselves, Aspen strongly supports and encourages "official" protection of works such as trademarks and copyrights. These protect not only the investment necessary to maintain the works but provides the seal of approval needed for official coding advice.
The question of "ownership" of the coding/classification system is complex and may best be addressed through the formal establishment of a partnership or consortium of several organizations in both the public and private sector. Aspen merely underscores its belief that a strong public/private partnership is necessary so that all parties can bring their issues to the table and have those issues recognized and addressed as soon as possible.
It is certainly clear that the creation, maintenance, and revision of any code system is resource intensive, complex, and time sensitive. Regardless of whether a system is in the public domain or in the private sector, the need to keep systems up-to-date is a significant factor in the Committee's decisions. Widespread input to any system will help achieve its acceptance and allow for a more rigorous system in that diverse coding communities will have the opportunity to have input to make the system more responsive to their individual needs, and collectively, will provide for more utility of the system across practitioners, settings, and users. Another factor relates to the public sector's ability to fund the continued development and maintenance of any system in the public domain, with or without private sector assistance.
Question 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?
A "simple" change from ICD-9-CM to ICD-10-CM/ICD-10-PCS will require tremendous resources in terms of computer programming, generation of new print material(s), curriculum changes in the educational sector, training costs and transition period costs associated with migrating from one system to another. This will be a prodigious effort all by itself, not to mention the issues already at hand in the year 2000 for the computer industry. The cost benefit analysis of the conversion from any one or more of the existing systems is an interesting question. However, we are not sure that any one of us can, at this point, place a specific dollar figure on what the numbers will be.
Wouldn't it be ideal if we could establish performance measures against which we could measure coding system performance? Then years from now we could look back on this effort and state explicitly what we hoped to achieve by the change from one code system to another. We would then have a way to quantify the results.
On the other hand, we must also ask questions about when or if the current systems will collapse from obsolescence and what would the cost be if that does happen?
Question 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?
Aspen fully supports the Department's efforts to standardize health data and streamline processes related to maintenance and distribution. Data standardization will make it easier in theory for us to code data, but the existence of standards or the adoption of specific code systems in and of itself has not, and will not, force all data collectors into compliance. Aspen suggests that the Department consider invoking its full authority to ensure that all requesters of health data are required to accept the standard codes and vocabularies established, and maintaining the integrity of coded clinical data for analysis and decision-making.
The Department's effort to prevent individual data collectors (be they state or federal agencies; claims processors; or private organizations under government contract) from straying from the established standards; definitions; data layouts, etc will go a long way to the attainment of administrative simplification and uniform reporting of data. The efforts underway must maintain clear objectives and consistent strategies. We should be very sure that any new or revised system embraced in the future is established along with a clear set of polices and pre-determined guidelines. Policies and code interpretation should "stick like glue" to the pre-defined standards in order to assure consistency in data reporting and subsequent data analysis.
It might sound strange coming from a company with "Systems" as its middle name, but remember that for the foreseeable future, codes will indeed be assigned by humans--albeit trained and certified specialists. Any schema must take into account the psychosociology of learning and change so as not to throw the baby out with the bath water. Let's see that would be code number......
This concludes our formal response to the Committee's main questions. We have chosen to also include responses to some of your additional questions in our written documents. Again, Aspen Systems Corporation is honored to have been invited to participate in this important initiative. We appreciate the time the Committee has allowed for us to provide our opinion regarding the issues at hand. We would be happy to provide additional information at your request. Thank you very much.
Question 1 - Can one system serve most if not all purposes e.g., clinical care, surveillance, quality assessment/improvement, clinical research, billing/management? If not, which systems can serve most of these functions?
No single system will meet all the needs of all users equally well at all times. At times, from a practitioner's perspective, it is less a question of multiple systems and more a question of multiple methodologies for application of available systems. Although sources exist to provide guidance and official coding rules with regard to specific coding systems, their existence does not guarantee consistent application and therefore consistent reporting. Thus, at times, coded data becomes a subjective data set.
Further, users vary greatly with respect to their level of automation and sophistication regarding policy implementation. Aspen would recommend that, if a single system approach is a viable goal, attempts are made to implement a system that meets the lowest common denominator of need and capability, such that it would have some level of application for all users.
Aspen suggests that the Committee be mindful of the coding community of users in the largest sense. Practitioners, providers, and users of coded data are diverse. Even today in 1997, the technical and technological limitations faced by some should not be understated. The ability of users to obtain coding resources is often limited by budgets. The awareness level of users varies widely. In our consulting practice it is not unusual for us to work with clients using out-of-date code books, no code books, and no computers. Thus, we strongly urge the Committee to consider, at least in the short term, recommendations that are feasible for the vast majority of users and not just those technologically endowed. The recommendations must work for the large tertiary care and university based medical centers; the small community health clinics; the individual practitoner, and the multiple- state managed care organizations. In the long run, of course, we need to consider ways to bring others along the technology continuum so that more innovative solutions can be explored.
Question 2 - Is it administratively simpler to use the same disease classification for administrative transactions and for statistical reporting?
We believe that it is indeed administratively less burdensome and simpler to use one system. It is always preferable to have one set of rules and guidelines to remember and apply. Administrative difficulties arise when various healthcare entities invoke the latitude of deciding what will be considered acceptable for their organization. Further, it seems that the lines between reporting health data for administrative transactions (payment?), statistical reporting and other uses (outcomes measurement; public health reporting) are, at best, not always clearly demarcated and, at times, quite fuzzy. If a user would have to label the use for which data were reported and then figure out which classification system he/she needed to use, administratively speaking things would be messy, burdensome and not well defined.
Question 5 - What are the impact on and implications for current (and emerging) medical/clinical classification systems as we migrate towards computer-based patient records (cpr)? To what extent can the major classification systems currently in use serve, in part, as vocabulary for the cpr, and if another system is recommended as the vocabulary for cpr, how can we assure that it crosswalks relatively easily to the classification systems currently used in administrative and financial transactions?
Efforts within the healthcare industry to develop and implement the cpr continue to surround us. Providers have long recognized the need to maximize the effectiveness of healthcare delivery through the use of automated systems. The capability to capture, manage and take advantage of computerized data and information is essential to continuously improving excellence in health services research and public policy. Nevertheless, the industry remains in a state of flux and there continues to be documented variations across providers and provider sites regarding their level of automation and their satisfaction with existing systems.
Certainly as the Committee moves forward to make its recommendations for standards in coding and classification systems, consideration should be given to the future technological advancements that we are apt to see the cpr. Medical information systems specialists, lexicographers, information science specialists, as well as medical informaticians, coders, and clinicians will all have important roles to play in the evolution of and application of standardized vocabularies and coding systems in the cpr.
Question 8 - Is it practical to move to a single procedure classification system on the timetable required for initial implementation of administrative standards or should the standards continue the current practice of requiring different procedure coding systems for the ambulatory and inpatient sectors?
Unless the Department is considering a move to standardize (make parallel) the way in which inpatient and ambulatory services are reported (i.e., a widespread move to APGs), wherein supplies, medications, drugs, etc., are bundled into the facility (healthcare provider) payment, it does not necessarily seem practical to move to a single procedure classification system at this time. The very nature of ambulatory reimbursement at this time (generally speaking) makes a separate classification system both useful and necessary. Should ICD-10-PCS come to fruition on schedule, and should APGs be widely implemented, the Department may then wish to consider a single procedure classification. An analysis of the appropriateness of the systems currently in use would have to be undertaken at that time. Additionally, Aspen would encourage the Department not to consider these issues in a vacuum, but rather would recommend that all with a vested and valid interest in the topic be accorded the opportunity to state their case.
Question 9 - If a medical/clinical code set or classification system is selected as a standard, should providers be able to use all the available codes within the set or system or should those requiring the information (e.g., payers) be allowed to restrict reporting of certain codes?
We have stated our position on this issue several times throughout our remarks, but would once again like to emphasize that the dilution of coded clinical data by financial reporting constraints is a long-standing issue among health information practitioners. Aspen contends, on our own behalf and on behalf of our clients, that coding guidelines and correct coding practice must be uniformly applied and accepted. From a provider's perspective it is quite cumbersome to have to constantly alter data reporting practices payer by payer. Also, such manipulation of data reporting results in payer influenced statistics. When payers restrict reporting of certain codes then those diseases or services or treatments are under-reported.