Sunday, March 09, 2014

Let's spend time calling instead of coding

Way back in 2008, my friend and colleague John Halamka wrote this post about the transition from ICD-9 to ICD-10 codes, the codes that are used to record clinical activity for the purpose of reimbursement by Medicare and other insurers. John is the unquestioned national expert in health care IT systems. At the time, he was "enthusiastic about the adoption of new standards that enhance semantic interoperability. The use of modern vocabulary standards such as ICD-10 improve administrative efficiency, enhance the ability of decision support systems to enforce guidelines, and enable a more granular reimbursement process." But, he also pointed out the logistical and training problems inherent in this kind of transformation:

The overall cost of implementing this change is technological and operational. For example, there must be modifications to existing training curriculum as well as claim submission and payment policies to ensure no adverse impact to the revenue cycle. I anticipate a real challenge to train, recruit, and retain ICD-10 savvy coders.

Well, that may have been one of the biggest understatements in health care for the decade.  As I have traveled the country, few issues have raised more concern than this one. 

By 2011, John Halamka was warning us:

If Congress was doing its job of regulatory oversight, they would sponsor hearings to learn what payers and providers are actually spending on ICD-10 conversion. Costs for consulting services alone run into the millions. This does not count the application software conversion, training and education, and other "in-house" costs. At our medical center, we would be paying $380,000 according to HHS estimates. Instead, the marginal cost of ICD-10 will be in excess of $5m. For multi-hospital systems, the costs may exceed $100m.

A Congressional review of transition costs would turn the regulatory impact assessment on its head. Costs could easily become double the estimated benefit savings.

With ICD-10, the government is perpetuating a reimbursement system that is far too complex. We spend more than any other country on healthcare administrative overhead. The Medicare Claims Processing Manual, for example, is over 4,000 pages in length. The reimbursement system needs simplification to bring the cost of this function in line with other industries.

In 2013, he noted:

We learned from that end to end testing with a full user load and complete data set is important to validate the robustness of an application. ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away. Does CMS have time for a full end to end test of all functionality with its trading partners? I am concerned that not enough time is available. Will most payers and providers be ready to process transactions on October 1, 2014? Maybe. Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place? Doubtful. Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign? Certainly. The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US. The consequences of a delay in enforcing ICD-10 use are minimal.

There have been lots of similar requests to the government to slow this down, but the CMS administrator is holding firm to the latest deadlines:

Providers, payers and claims clearinghouses can look for no relief from the looming, Oct. 1 compliance deadline for the nationwide conversion to the ICD-10 family of diagnostic and procedural codes, the head of the CMS said Thursday.  

Tavenner's comments triggered a quick, and apprehension-filled, response from the American Medical Association.

“The AMA is deeply concerned that Medicare does not have a back-up plan if last minute testing demonstrates anticipated problems with this massive coding transition,” said AMA President Dr. Ardis Dee Hoven.

Many doctors are still awaiting software updates from vendors and risk not having sufficient time to test those updates when they finally do arrive, Dee Hoven pointed out. “Testing is needed to discover problems and resolve them prior to the go live date. The slightest glitch in the ICD-10 rollout could potentially cause a billion dollar back-log of medical claims that jeopardizes physician practices and disrupts patients' access to care,” she said.

So, the training goes on.  Barnes Jewish Hospital in St. Louis, for example, has prepared thousands of "tip" cards like the ones above to help people remember some of the details required under the new coding environment.

Meanwhile, this has become a big business.  Here in Boston, one IT firm is even advertising on public radio (!) that is it available to help health care facilities manage the transition.  (I guess that just shows how many health-care-related NPR listeners live here!)

I guess this is all necessary, but I'm not sure I really understand why.  For example, if the trend in the US really is towards global, or capitated, payments, why do we need record-keeping of such detailed clinical activities?  Also, this new required level of detail creates immense compliance risks for doctors and hospitals and enforcement needs for regulators. It seems to me that the chance of inadvertently coding something wrong has just increased by two or three orders of magnitude.

 The CDC summarizes:
  • There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3
  • There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM
  • ICD-10 has alphanumeric categories instead of numeric ones
  • The order of some chapters have changed, some titles have been renamed, and conditions have been grouped differently
Given the government's recent focus on enhanced billing compliance, we can expect many more investigations and financial penalties.

I'd prefer that providers be allowed to spend more time calling their patients and talking to them about their conditions rather than coding their illnesses.

Meanwhile, there is some humor in the situation:


Brad F said...

In a capitated world without recording of administrative data elements (until we can scour using natural language), how do we build data registries, record CMI, and study practice patterns?

I assume you wish to keep an ICD-lite?


Paul Levy said...

Garbage in, garbage out. If people really don't know how to use these codes, they won't do all that might be hoped for.

Would love to hear from experts: Maybe we're close enough to natural language recognition that we could achieve goals you set forth more easily.

Medical Quack said...

Dr. Halamka is always right on target and it's kind of an unspoken that his wisdom guides the ONC anyway, all you have to do is read his blog and it's all there:) Now back on topic with the ICD10 issue, yes is it's a money maker for selling the software and as I have have said so many times before, Sebelius and Tavenner are way over their heads when it comes to being on top of technology and that fact goes for Congress too and most of what we have there in DC, part of the White House too. I did a post a short while back on a hospital that has to go out and get a line of credit as they are that poor for the transition..and what they are anticipating of course is the delay of payment and anyone this day and age that doesn't think that will happen with the complex IT infrastructures we deal with today better go head their head examined. You can read it yourself and all hospitals are not equal and it makes a difference with demographics and mix as you well know having been there done that.

CMS finally came to their senses with end to end testing which they were not even going to do so tell me after Healthcare.Gov is "trust me" anywhere in here:) Back in 2009 when Sebelius was nominated, I said Health IT, give a few years would eat her up...any arguments there:) I'm a former code writer myself so folks that do this like me see it coming long before it hits.

You know what, pretty soon we are going to have mass burials for the software engineers dying of exhaustion at the keyboards (grin)..a little satire there but true in the fact that since everything is out of the silo, can't do like we used to and yeah when it comes to software updates, I miss those silos like every other developer when it comes to time and complexities but it's not the world we have today.

I just started calling it the Sebelius Syndrome and she's not the only one who has it, add on Congress, the RNC...and on and on. I got in there with some pretty heavy tech talk on and told reporters that call me I'm going to start charging them next time too:)

So yes, back on target here, this stands to be a huge disaster if the complex IT infrastructures are not ready to roll with all the algorithmic processes in place..and everyone in tech knows it. Reporters don't do a very good job though as they still tell stories. So on that topic here's another post on their problems..looking for money and revenue streams. Did you know some of your news is bot written today...about 25% from Forbes who is up for sale.

It's called the Journobot and my friend Charlie Siefe at NYU has a new book it the works, he's a mathematician and journalist and one whole chapter, the journobot:) Watch the 2nd video here and see the process as the creator wrote 10k books in a short time with it and put them on sale at Amazon. We have a little too much quantitated justification for things that are not true out there. This is fact and not a opinion at all, it's the real deal on what runs on servers 24/7, some of it making life impacting decisions about all of us.

Dr. Halamka is right on the mark and and of anybody out there in Health IT, all should give them their ear. There's nobody else out there like him and we have math models that continuously lie for profit. If go to the bottom of my blog, 4 great videos that they layman can get bring you up to speed...and I learned a lot talking to quants for sure and look at all the quants being hired by insurers.

In short ICD10 is throwing a ton of new code and algorithms out there that have to play together, just like the markets so see anything similar there:)

I'm done now:)

Anonymous said...

The rest of the world does it. We should either do it, or give up on pretending any semblance of our system has been working for the past decade. Everything we want to do and are behind the developed world in, we cite as too expensive- and I know ICD 10 really is. But its only too expensive because we insist on keeping a fragmented system in place where everyone currently involved (and complaining) has an interest.

Anonymous said...

Yes, most of the world uses ICD-10 but NOT for billing purposes. Epidemiology, Population Health etc.
Anticipating the angst of October 1st, we've developed and recently released an app that may help alleviate the anxiety related to the ICD-10 implementation. Especially for the small practices that don't have the support or budgets of a hospital HIM department.

You can check it out at

The funniest code IMHO is the very common injury of... "V91.07 Burn due to water skis on fire"

Even with our app we couldn't find any code for "Major depression due to ICD-10 implementation" though

Lisa researching calling hospital said...

Do many people suffer burns due to water skis catching fire?