I would like to thank the Committee for the opportunity to express Medicode's views on the current coding and classification systems. Medicode develops and maintains large healthcare information databases built upon CPT-4 (both physician and hospital versions), ICD-9-CM (both diagnostic and procedure classifications), HCPCS, and CDT-2, NDC, as well as the various state workers' compensation coding systems. We disseminate our information (claims editing, pricing, utilization, cross-coding) to all aspects of the healthcare industry.
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?
The following list represents the common coding/classification systems used in our products:
We strongly feel all coding /classification systems should be evaluated as this country struggles with diminishing the costs and time spent on administration of healthcare. The ultimate goal should be the fewest number of systems with the greatest degree of usability. The granularity, type , and use of information needed by this industry should be determined before any decisions on how that information is reported are made. It is somewhat disconcerting that we may not have a clear vision of "what" the information is which will help us make healthcare policy decisions now and for the future. Instead we appear to be making greater strides with the "how." It's tough to draw a map when you don't know where you're going. Simplification is a lofty goal but in and of itself it lacks vision and might have greater impact potential when coupled with a clear knowledge of the needs of each stakeholder and how those needs can be leveraged.
The following list examines the strengths and weaknesses of the coding/classification systems are most commonly used:
--While the main purpose of the ASA guide is to attach relative values to anesthesia codes (the codes also appear in CPT-4), the process is complicated by addition of new codes which are sporadically introduced within the guide and do not appear in CPT-4.
--Allows most accurate reporting of brand, form (tablet vs. liquid), packaging method (injectable vs. oral), and quantity or volume
I've included state workers' compensation fee schedules in this discussion because they are not purely fee schedules but function also as coding systems. While state fee schedules are generally based on CPT-4 codes, most states introduce codes they've developed themselves. Some states include as many as seven hundred additional codes. As use of these state-specified codes becomes more common they are reported on HCFA-1500 forms to local commercial payers, who add them to their systems to allow payment. The result is permanent alteration of the coding schema in several geographic areas.
While these variables could certainly impact efforts to collect standard utilization and outcomes information on a national basis, I think they also serve as an indicator that we need to clearly understand what all entities in this industry are trying accomplish in order to provide the right vehicles to gather it.
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?
With the goals of simplification and clarification coupled with the need for standardized data to allow for more informed healthcare policy decisions, a step-by-step transition of standard national coding for reporting needs to be formulated--even if only the first phases are accomplished within the timeframes of HIPAA. For example, CPT-4 is a current industry standard which is inadequate as a data collection tool and is becoming increasingly difficult to maintain. A schedule for transitioning CPT-4 to ICD-10-PCS by the year 2001 could be developed provided the PCS field trials are successful. CPT sections not currently included in ICD-10-PCS, e.g., evaluation and management services, could be developed by the AMA and incorporated into the PCS for HCFA to implement.
The following paragraphs outline steps which could be undertaken to provide the basis for reporting continuity within the confines of HIPAA:
--HCPCS should become a durable medical equipment coding system only. Those codes describing professional services, regardless of provider type, should either be included in CPT-4 or made part of an allied health professional services coding system..
Discontinue the policy of establishing temporary HCPCS codes--determine the need, for example, for a new code within a schedule which would allow for the code's inclusion into the classification system.
Once the number of necessary coding systems diminishes and the data focus within each remaining system is the same, transitioning to a final, national standard--if indeed that is the goal--becomes a more manageable task with diminished disruption to the industry.
Another critical step to the success of this subcommittee's labors is increasing the granularity of all indexes. These indexes not only improve arriving at consistently correct code choices within a book, they also serve as the basis for search and choice capabilities in computer programs. Common lexicons are important--especially if the task is to calibrate severity of illness or injury in order to link medical services appropriate to severity--however, they can be self limiting. How robust a program is can often be linked to the level of detail embodied within the search algorithms or text. Descriptors of all types (from brand names on equipment or drugs to a regional physician's name attached to a surgical procedure) will provide the breadth of knowledge necessary to code today's as well as tomorrow's medical record.
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?
The United States has made similar changes in the past and lived to tell about it. Granted, the entire healthcare system was less sophisticated then than it is today, however, this statement makes it imperative. The healthcare system will be even more sophisticated ( especially in terms of dependence on coding to allow for more complex billing, editing, payment and evaluative systems) tomorrow. Putting off the move will certainly not make it any easier and may very well allow important data to "slip through the cracks" as the current diagnostic coding system is stretched to capacity. The same conviction holds true for ICD-10-PCS--at the very least, replacing ICD-9-CM Volume 3 can't come soon enough.
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?
I gather from the phrasing of this question that your concern centers on being charged with simplifying administrative burden while contemplating massive change which would be anything but simple. The honest answer is the change itself isn't simplification but once implemented, the new coding system will be simpler because the new classification is more consistent in its conventions and more able to accommodate new diagnoses, procedures and technologies.
I am certain the members of the Coding and Classification Implementation Team are developing a detailed implementation and training plan. Involving commercial field coding consultants would also provide increased public awareness and likelihood for indepth training at no additional cost to NCHS or HCFA. The implementation period is so generous that programming and training should not be difficult for payers, providers or their vendors. As long as communication on progress and/or changes are consistent and plentiful the process shouldn't present an undue burden on anyone. I know we're already evaluating the programming and mapping/crosswalk needs to preserve the usefulness of our datasets and edits programs.
Unfortunately, the current coding environment isn't simple--there are rules so diverse they are in opposition and any reduction in administrative burden would require evaluation of these systems for areas where more distinct guidelines are needed. Some of the suggestions I listed in question two could still be implemented but would require mandate because there is little or no incentive that it is in the best interests of the end-user to "prepare for change."
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?
Public Domain
Pro
Con
Private Sector
Pro
Con
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 weight the costs and benefits of making such changes?
Medicode has been mapping massive healthcare databases to one another for some time. We are accustomed to the base coding systems changing at disparate times on or off a promised release schedule. At the outset, the issue is just another mapping exercise--how do you relate data from one system to another? Certainly not rocket science but definitely one of planning and tedium. Other considerations are reprogramming to accept alpha characters where only numerics were programmed in the past or changing field size to accommodate more digits per code as well as computer storage space for the additional mapping. Again, viewed as individually planned tasks, none are too earthshattering.
A far greater challenge to time, human and monetary resources is the clinical decision-making which must take place to develop the editing/unbundling rules tables for both diagnostic and procedure codes as well as evaluating the mapping exercises from the old system to the new. Based on similar tasks, a rough estimate of programming and clinical costs would be $500K to $750K to update all databases and subsequently all products. I did not include marketing and sales costs or production costs since these occur independent of content. Spreading these costs across the various products we offer would represent an increase but not a particularly burdensome one. The additional cost per unit would likely be further reduced because historical data shows that massive change increases the need for new products which increases sales. Larger volume means the increases are less on a per unit basis.
The overall industry affect of these increased costs is difficult to measure. Both providers and payers are likely to increase their administrative spending on training. Some providers and payers may see little or no increase as they pay for their system use on a "per transaction" basis with multi-year contracts allowing for CPI increases only. Their main impact becomes one of training to regain familiarity and efficiency. Once familiar, especially given the long implementation period, speed and accuracy should increase.
To maintain consistent reporting for accurate data collection, HCFA and NCHS should provide an "official" map from the old codes to the new. Should resources be a problem for these government departments, simple contracting with private industry would produce the desired result.
There are significant benefits to standardizing our numerous coding systems. The following list gives a broad overview of what these benefits might be:
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 to 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?
The Coding and Classification Implementation Team is comprised of industry experts who are imminently qualified to put this plan into effect. I would suggest, however, the implementation plan itself be widely disseminated to allow as many end-users and vendors as possible the ability to measure their own progress.
Additionally, some caution should be exercised in limiting the coding and classification vocabularies. A standard vocabulary indicating severity is essential, however too restricted a word set can lose potential granularity necessary to assure accurate code selection and computer search mechanisms.
I would like to thank the committee for the opprtunity to present these views and look forward to working with you in the future as this process continues.