Good morning ladies and gentlemen. My name is Dr. Larry Griffin and I am an obstetrician-gynecologist and the Program Director for the American College of Obstetricians and Gynecologists (ACOG), Department of Program Services.
ACOG, an organization representing more than 37,000 physicians specializing in the delivery of health care to women, is pleased to have this opportunity to comment on the use coding and classification systems for administrative and financial transactions. The vast majority of our members are in the active clinical practice of medicine. They serve as the initial entry point into the health care system for the majority of women of reproductive age in the United States. In addition to providing a full range of reproductive health services, obstetrician-gynecologists also provide a wide range of primary and preventive health services to women. ACOG has supported and continues to support coding and classification systems that permit accurate collection of data and appropriate reimbursement and services rendered. Our comments today address the questions put forth by the Subcommittee on Health Data Needs, Standards and Security, and reflect the impact of proposed coding system changes on the provision of health services for women.
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?
Physician members of the American College of Obstetricians and Gynecologists predominately use CPT-4 codes to report procedural services and ICD-9-CM diagnostic codes to describe the justification for the procedures performed. These two type of codes are submitted to third party payers to obtain reimbursement and to report services in non-payment situations. They generally allow accurate reporting (through the use of codes, qualifying CPT numeric modifiers, and diagnostic linkages) of professional services rendered by physicians in any setting (e.g., office, inpatient hospital, outpatient hospital, etc.).
While CPT and ICD-9-CM codes have been generally recognized by the majority of third party payers, some payers still mandate the use of internally developed procedural codes which are used to control or monitor specific targeted services rendered to the beneficiary population. For instance, Medicare has recently developed a set of alphanumeric codes to report excision of pre-malignant and benign skin lesions although there are existing CPT codes to report these same procedures. In addition, some payers do not recognize all of the available diagnostic codes in ICD-9-CM or the CPT procedural modifiers thus limiting the collection of accurate data.
The current strength of the CPT coding system is the involvement of physicians in the process. This allows physicians who perform the procedures to determine the appropriateness of the procedure or condition being coded and to recommend the correct nomenclature when new codes are developed or old ones revised. The current weaknesses of this system are the length of time it takes to add new codes when technology changes, the fact that non-physician or physician-directed services cannot be reported appropriately, and the fact that the codes are considered by the AMA to not be in the public domain. This latter weakness has in the past hampered efforts on the part of medical specialty societies to educate their members regarding accurate and correct coding practices.
The ICD-9-CM diagnostic coding system has several weaknesses, at least one of which will be corrected with ICD-10-CM. First, there is limited ability to revise or add new codes based on morbidity conditions found in the US Second, the ICD-9-CM codes are reported in different ways by physicians and hospitals. For instance, the physician will link a specific diagnosis(es) to a specific procedure code. Hospitals, on the other hand, list diagnoses from the patient's chart based on the severity of the condition. If this order coincides with the primary reason the physician admitted the patient to the hospital, there is no conflict. But, for example, if a patient is admitted for delivery and post delivery suffers a stroke, the stroke diagnosis will appear as the primary diagnosis. For data collection systems that cannot capture all diagnostic information, valuable data can be lost.
The strength of ICD will lie in ICD-10-CM because of direct input from physician users about conditions that cannot be currently coded. In our opinion, ICD-10-CM will allow better information to be collected.
Note, however, that the greatest potential weakness of any and all coding systems is the inability to report information or capture data. Many third party payers do not currently capture more than one diagnostic code, cannot link procedures and diagnoses even with electronic claims submission, or refuse to recognize all of the diagnostic or procedural codes that are currently reportable. It will be difficult to make sound decisions about coverage and national health needs without the presence of accurate data.
We strongly recommend that if a single coding or classification is eventually adopted, a uniform set of rules and definitions must also be adopted and required by all parties involved in health care information or transactions.
2. What medical/clinical codes and classifications do you recommend as initial standards for administrative transaction, given the time frames in the HIPAA? What specific suggestions would you like to see implemented regarding coding and classification?
At this time, we believe that CPT-4 and ICD diagnostic codes should continue to be used to report physician services. Changing reporting systems before there is adequate time to prepare and accept them, would be equivalent to changing to the metric system overnight.
The most accepted system at the moment is CPT-4 and ICD-9-CM. Code information comes in a variety of venues; CD-ROM, diskette, printed books. Physicians create encounter forms or inpatient procedure records which assist office staff in billing services rendered by the physician. The price to the provider for a yearly subscription or yearly updates to the new and revised codes is minimal.
As we have noted above, however, such acceptance has not precluded third party payers from developing their own internal coding systems for both financial and administrative purposes. This adds to the administrative burden and makes it difficult to cross-walk the various data bases.
3. Prior to the passage of HIPPA, the National Center for Health Statistics initiated development of a clinical modification of ICD-10 (ICD-10-CM), and the HCFA 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-HIPPA 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?
ACOG has been an active participant in the process of developing ICD-10-CM diagnostic procedures that would be reported in conjunction with gynecologic and obstetric services. This new system appears to allow for the expansion of the diagnostic codes to better serve the data reporting needs in the United States. These diagnostic codes can also be used for many different reporting situations (ie, physician and hospital and administrative).
We have recently begun a review of the ICD-10-PCS system and will presently be making comments to 3M Health on this system. Our preliminary opinion, however, is that it is cumbersome to use and will almost certainly lead to incorrect coding unless those responsible for assigning and recording procedure codes are exceptionally well-versed in the mechanics of the procedures and the terminology used by various physicians. Using this system, procedural codes can only be formulated after careful scrutiny of the operative report. This will increase the time required to record inpatient data. We have also noted that although there has been an attempt to standardize definitions, some basic procedures may have more one than one definition and the definitions often conflict with generally accepted medical terminology. For instance, a total abdominal hysterectomy is classified as a "resection" while a supracervical hysterectomy (where is cervix is not removed) is classified as an "excision." Additionally, and more importantly, if a decision was made to select ICD-10-PCS for reporting all procedural information (on physician submitted claims for professional services as well as for inpatient claims) the administrative costs of doing so for physician practices could be astronomical. This could easily lead to upward pressures on the price of health care services and a loss of valuable data.
In summary, we would support the use of either ICD-9-CM or ICD-10-CM for reporting diagnostic information for most data collection requirements, but we would have very grave concerns about using ICD-10-PCS at this time.
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?
If administrative simplification implies collection of abbreviated data, the goals of reduced administrative burdens and medically meaningful information cannot be accomplished. Part of the administrative burden in today's health care environment involves the additional and needless cost of having to maintain extensive information about reporting the same service to each different third party payer. In spite of the fact that the majority of payers accept and recognize CPT and ICD-9-CM codes, the rules under which these codes can be reported are varied and often at odds with one another. Some notable examples include: refusal of several payers to accept numeric modifiers; mandating the use of a CPT code, but applying a definition to the code that is substantially different from the CPT definition; failing to standardize the mechanics of coding over all contracts administered by a given insurer. All of this variance translates into additional needed resources which add to practice expense and overhead costs. This comes at a time when third party payers are dramatically reducing reimbursement; in some cases below the cost of producing the service.
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?
The maintenance of medical/clinical code sets will need the input of physicians to be effective. Funding for such maintenance can be reduced when input is obtained through voluntary participation of medical specialty societies and other interested parties. The code sets would be more useful if kept in the public domain for contributors to the process because it allows for unhindered access to the codes and standard guidelines for educational purposes. Coding education through the medical specialty societies, for instance, has helped to reduce reporting errors, thus decreasing the administrative burden on physician practices and insurers as well as having a positive impact on data collection. If the codes are kept in the public domain, even with copyright requirements, there may also be an opportunity to offset the costs of maintaining the codes by charging a user fee to those companies or organizations that do not contribute to the development and maintenance of the code sets, but who profit in the production of coding materials.
6. What would be the resource implications of changing from the coding and classification systems that you currently are using in administrative transaction to other systems? How do you weigh the costs and benefits of making such changes?
Changing to a different coding and classification system may involve several additional expenditures for physician practices. It would almost certainly involve additional staff and physician training and perhaps could lead to the substitution of higher qualified coding staff for current staff. This would certainly raise the practice expenses for the practice, not to mention lengthening the time between when the service was rendered, when it was reported and when it was reimbursed.
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 follows. 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?
We have, at this time, no comments concerning the process being undertaken to carry out the requirements of the law in regard to coding and classification issues.