PRESENTED BY
CHARLES VANCHIERE, M.D., F.A.A.P.
APRIL 15, 1997
Dr. Starfield, members of the Subcommittee on Health, Data Needs, Standards, and Security, my name is Charles Vanchiere, M.D. I am here today to represent the American Academy of Pediatrics, an organization of over 53,000 pediatricians, pediatric surgical specialists, and pediatric medical subspecialists committed to the attainment of optimal physical, mental, and social health for all infants, children, adolescents, and young adults. I want to thank the Subcommittee for inviting the Academy to participate in this timely discussion on the future of clinical coding and classification systems used in administrative transactions. In testimony today, I will stress the importance of proper clinical diagnostic and procedural coding and other classification systems and the significant impact their use will have on children's access to quality health care. The Academy also stresses that any coding or classification system employed for administrative transactions guarantees continuous review by the entire medical community, as well as promotes the capacity for the documentation of pediatric procedures, diagnoses and diseases.
Current Coding and Classification Systems
Even as we speak, the Academy and other medical societies are working actively within the CPT process and with other medical societies to examine and recommend solutions to the coding disparities that exist for pediatric care. Only with continued participation of medical societies and health care professionals, will these disparities be eliminated and children's conditions be given balanced representation in the classification systems. We believe that any deviation from the current system of procedural coding may damage the recent advances made for pediatric specific services, and encourage the Subcommittee to maintain the current system of procedural coding while promoting its applicability to pediatric care.
Historically, pediatric services have not been incorporated in Physicians' Current Procedural Terminology (CPT) to the degree we feel necessary. This system of procedural coding has been limited by the substantial number of advances in medicine and technology for which procedural codes have been required. Often, these procedures need to be incorporated into the existing coding and nomenclature structure within a condensed time frame. The process of review and acceptance of new or revised procedural codes within the CPT system also has been constrained by the limited space available for expansion. However, it appears that those who maintain and update CPT are aware of the inefficiencies of the current system and that these issues are being addressed.
The American Academy of Pediatrics also has played an active role in reviewing various chapters and sections of the impending International Classification of Disease Tenth Edition, Clinical Modification (ICD-10-CM), and we believe that these segments represent a significant improvement over the current ICD-9-CM coding system in layout and category specification for pediatric diagnosis and disease documentation. The staff and members of the various governmental committees that maintain and operate the ICD-9-CM have been receptive to many of the AAP's comments.
E-Codes
It is essential that any diagnostic classification system require the use of ICD-9-CM E-codes to document external causes of injury and factors influencing the health status of children. We support the preliminary indications which suggest that ICD-10-CM will expand upon this foundation and provide additional classifications to further clarify external causes of illness.
The benefits of using and reporting ICD-9-CM codes, including E-codes, by physicians and hospitals are numerous. The Academy believes that "more complete and accurate surveillance of injuries to children will help health professionals, including pediatricians, plan and implement health promotion and prevention programs, as well as evaluate program cost and quality." The current ICD-9-CM E-codes achieves this in part by assisting health care professionals in determining and examining risk factors associated with childhood injury, documenting the morbidity and mortality associated with these risk factors, and identifying demographic and geographic dissimilarities in injury, as well as detecting injuries related to new products and technology. It important to underscore that E codes are a source of data for health care professionals working to make health care more effective and an important and effective means of assessing the impact of such injury prevention legislation as bicycle helmet requirements, environmental hazard laws, and seat belt and care seat laws, at local, state, and national levels.
DSM-PC
Mental health diagnoses and services also must be appropriately documented, classified, and coded within a medical/clinical administrative transaction classification system. The Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version is the most comprehensive source of mental health classification information. It was developed to facilitate the understanding and coding of child and adolescent mental health issues by primary care providers. This manual is both an operational instrument for the diagnosis and classification of child and adolescent mental health conditions and a mechanism for the coding of these disorders.
Risk Adjustment
Coding and classification systems should also be sophisticated, yet practical enough to facilitate risk adjustment at both the individual patient and population levels. Administrative data must promote the linking of data at the patient level and over time. With such linked data, one can identify conditions treated previously that could thus be considered chronic or preexisting. One can also look at patterns of diagnoses over previous hospitalizations or health care encounters to draw inferences about the course of illness. Longitudinal, or time-linked data, will facilitate patient tracking across both services and time. The ICD-9-CM does not paint a complete clinical picture of all dimensions of risk. This is aggravated by the fact that CPT does not readily link to ICD-9-CM. New coding and classification systems must be able to overcome these problems to ensure the successful use of risk adjustment mechanisms in capitated environments.
Specifications for Implementation
It is crucial that any standardized coding and classification systems selected for administrative transactions include annual updates, through a process of quarterly review that encourages physician participation. We believe that the idiosyncratic acceptance and denial of procedural and diagnostic codes is problematic, causing delays in the provision of necessary services. In order for physicians to incorporate a system of coding and classification into their practices effectively and efficiently, the system must be universally accepted and exclusively adopted, not adapted, by all health care providers, insurers, and federal and state agencies. Any system that is promoted for use within all phases of medical and clinical coding and classification should be kept within the public domain without the restrictions associated with copyright laws to guarantee accessibility and availability of information for use by health care providers as well as for purposes of education and research.
We believe that as the medical practice of pediatrics has evolved, so have the current coding and classification systems. Familiarity with the existing procedural and diagnostic coding systems has created a level of comfort within the pediatric community that will only continue to grow, ensuring the heightened use of these coding and classification systems. However, the Academy questions the ambitious time table for implementation of these systems. We believe that a 24 month period may not provide sufficient time for pilot testing and the incorporation of necessary modifications derived from pre-testing the coding and classification instrument. Additionally, the cost for the development and implementation of a new or modified coding and classification system would be astronomical for hospitals and physician practices alike, not to mention the coordination that such a dramatic and comprehensive alteration of coding practice would require.
The Academy appreciates your careful consideration of these issues and I thank you for allowing me to participate today in the discussion regarding medical and clinical coding and classification issues. I would be pleased to answer any questions you may have. Thank you.