The Transition to ICD-10: Who made it happen?

We decided to dig a little deeper into the forces behind the transition to ICD-10. Not surprisingly, one of the largest proponents of the new codes were government organizations. However, non-governmental organizations like insurance companies, patient advocacy groups, and health information technology associations also played a large role in the shift.  Let's take a look.

Nonspecific: One code for all of your troubles
On April 9, 2002, Nelly Leon-Chisen of the American Hospital Association (AHA) testified before the National Committee on Vital Health and Statistics (NCVHS) – the department that serves as the statutory public advisory body to the Secretary of Health and Human Services (HHS) in the area of health data and statistics – speaking to how ICD-9-CM codes were being used too generically, with individual codes covering too many unrelated ailments at once. Sue Prophet-Bowman of the American Health Information Management Association (AHIMA) made a similar argument to the NCVHS, pointing out that code 81.47 (“other repairs of the knee”) included both open and arthroscopic repairs.
 
In spring of 2003, the NCVHS asked the RAND Corporation to conduct a study of the costs and benefits of a transition from ICD-9-CM to ICD-10-CM. At the time, ICD-9-CM maintained the conventional code set, because ICD-10-CM was considered "not mature enough” for implementation.
 
Code sets within code sets
Fast forward to 2009. During the 10th Revision in the United States, ICD-10 was split into two coding subsets: ICD-10-CM (Clinical Modification) and ICD-10-PCS (Procedure Coding System). The National Center for Health Statistics (NCHS) developed the CM version of the code set, while The Centers for Medicare & Medicaid Services (CMS) created the PCS set.
 
On their website, CMS has released a variety of insight into the process involved leading up to ICD-10’s rollout. Members of the organization listened to the accounts of small practice physicians concerned that the transition to the new code set would be a massive undertaking, potentially crippling their practices. This led to the creation of the “Road to 10” resource center designed specifically for guiding smaller physician practices by providing primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation.
 
In response to suggestions by a number of physician groups, CMS named an ICD-10 Ombudsman and committed to a three-business-day turnaround for every question or concern submitted by a healthcare provider. Metrics were also put into place to monitor for detrimental effects of using the new coding set, like the number of denied claims and the overall number of submitted claims.  
 
The coalition had formed
During the three delays of the ICD-10 implementation, proponents of the new code set underestimated the power of their opposition, which had an unexpectedly powerful influence on the media. Considering that many other countries had already adopted a similar coding system years earlier, the negative response in the U.S. truly was a surprise. Finally, after the third delay to implementation, a diverse group of advocates realized the need for a new approach and formed the Coalition for ICD-10.
 
Participants spanned from all corners of the healthcare industry, including:
  • The American Hospital Association, which focuses on being effective as a trade organization and public interest champion.

  • The Healthcare Financial Management Association, a membership organization for healthcare finance leaders that builds coalitions with a variety of healthcare associations and industry groups to create solutions consensus.

  • The American Health Management Association, as a go-to source for health information management knowledge that implements professional education and training programs.

  • America’s Health Insurance Plans, the national trade association representing the health insurance community,

  • National Blue Cross Blue Shield, a national federation of independent, community-based and locally operated BCBS companies.

Their goal: Correct the course and urge both advocates and critics alike to engage in productive conversations about moving forward.
 
What now?
This third and, hopefully, final delay was implemented with a generous "grace period", a full year during which providers are encouraged to learn the code set before receiving penalties for imprecise coding. So far, researchers are finding that the transition is not producing the negative effects feared by many ICD-10 opponents.
 
In February 2016 RelayHealth Financial released a statement noting the the denial rate for more than $810 billion in claims processed between October 2015 and February 2016 was limited to 1.6% (approximately $12.9 billion), which it said was not a statistically significant increase when compared with denial rates prior to the implementation of ICD-10.
 
Comparing the transition to the technical fears of the new millennium, Debra Patt, MD, a practicing oncologist states, “Sort of like Y2K, there was not a big crash. Everything went on sort of flawlessly.”
William Rusnak, MD's picture

William Rusnak, MD

Medical Information Advisor

William Rusnak, MD (@RusnakMD) is a resident physician in diagnostic radiology, financial investor, writer, and entrepreneur. He writes about topics such as healthcare information technology, data science, biotechnology, and prevention of chronic disease. With his involvement in several emerging healthcare companies, he is actively attempting to bridge the gap between medicine and information technology.

comments powered by Disqus