AMA Renews Call for ICD-10 Contingencies

A hardship exemption is needed for physicians who've tried in good faith to meet the Oct. 1 implementation deadline, but who've been hamstrung by issues beyond their control, says the president of the American Medical Association.

Less than 100 days before the federally mandated switch to the ICD-10 diagnostic code, the American Medical Association is renewing its call for contingency plans to ensure that physicians struggling to meet the Oct. 1 implementation are not unfairly penalized, nor care disrupted.

"This transition to ICD-10, if it goes forward on Oct. 1, and that appears to be the current trajectory, [means] it is absolutely imperative that there is better end-to-end testing, a grace period, and hardship exemptions in place," says recently elected AMA President Steven J. Stack, MD.

Stack says the AMA has also called on Health and Human Services Secretary Silvia M. Burwell to exercise her prepayment authority "to ensure that claims get paid on a timely basis in those first weeks and months, and then as we navigate those early days of the transition so that the care system is not brought to a halt as hundreds of thousands of claims per day could potentially get disrupted."

Stack says physicians are not necessarily assuaged by assurances from the Centers for Medicare & Medicaid Services and ICD-10 advocates that sufficient testing is underway for the diagnostic code set that will replace ICD-9.

AMA Delegate Blasts ICD-10 Implementation Requirements

"Our major concern is that it is a 400% or so explosion in the number of codes," he says. "It's being treated like a flip-the-switch activity, where on Sept. 30 we use ICD-9 and on Oct. 1 one-fifth of the nation's economy is supposed to just on one day switch to an entirely new coding set that is over a 400% increase in the total number of codes."

"This fails to take into consideration that physicians are being compelled to do this at the same time that they are being compelled to do multiple different quality reporting programs, let alone all the private payer quality reporting programs," Stack says.

A survey of more than 800 providers released in March by the Workgroup for Electronic Data Interchange, found that only 25% of respondents had begun external testing of their ICD-10 capacity, a decrease from the 35% of providers who'd begun external testing in August, 2014.

However, the WEDI survey also found that the biggest hurdle was not so much the complexity of the implementation, but more the uncertainty around the Oct. 1 implementation date, which has already been delayed three times at the behest of the AMA and other provider associations.

"While the delay provided more time for the transition to ICD-10, many organizations did not take full advantage of this additional time and many providers are falling further behind," WEDI ICD-10 Workgroup Co-Chair Jim Daley said in remarks accompanying the survey.

The AMA has called for delays of the implementation, and even skipping ICD-10 and awaiting ICD-11, which by some estimates could become operable by 2020. However, Stack says the nation's largest physicians' society has also "moved forward in parallel to our advocacy because we have an obligation to ensure that physicians are as ready as possible so they can be there to take care of patients."

"We have encouraged physicians to follow guidance given by their organizations and by others that tell them to run the code set, compare their practices, make sure they prepare for what we are fearful will be significant disruption, where we could have physicians facing substantial disruptions with 10% to 20% of their claims starting Oct. 1," he says.

Stack says the AMA's call for a two-year grace period for physicians transitioning to the new code has been mischaracterized by some critics as foot-dragging.

"Our assertion for a two-year grace period does not very clearly assert that a person can code for a heart attack when in fact it was an ankle sprain," he says. "We are asserting that if we properly diagnose somebody with hypertension and say it's a new diagnosis, then the payers should not be able to deny a claim because we're unable to say that it was hypertension new diagnosis, secondary to renal disease, secondary to diabetes, secondary to poverty or some other things."

"When we get to these layers of specificity that ICD-10 permits, it is very important that payers not deny payment for lack of some falsely perceived level of specificity that the physician may not be able to provide, particularly as we learn the new code set and find a new equilibrium with all of those who are using it," he says.

Stack says a hardship exemption is needed for physicians who've tried in good faith to meet the Oct. 1 deadline, but who've been hamstrung by software or clearing house snafus and other issues beyond their control.

"All of those things would imperil patient access because the physician has an interruption of their claims paying process and has no reimbursement coming in for claims," he says. "Patients are going to find it more difficult to seek care because the physician is going to struggle just to keep the office open."

Lynne Thomas Gordon, CEO of the American Health Information Management Association, says the AMA's contingency plans would create confusion.

"The end-to-end testing, we know based on the testing that has already taken place that only 2% of the errors in codes in the last testing period were due to ICD-10," she says. "There are always going to be problems. We are taking the time to do the testing and get it right. Will it be perfect on Day One? No, because it's change and everybody will be getting used to it."

Thomas Gordon says most of the survey data indicates that it is the rural and smaller physician practices that are having the most difficulty. "If I were the AMA and I was that concerned I would take a representative sample of my members and get them to test and see what happens," she says. "They want more testing, but why aren't they doing it now?"

"As far as the grace period, what they are looking for is "do the best you can for two years, but don't penalize us,'" she says. "I would hate to be a payer in that situation. I would hate to be a hospital trying to compare things. It would confuse the market. You'd have some people forging ahead with ICD-10. You'd have other people who weren't. I've even heard some people say this grace period is another term for 'delay.'"

As for the hardship exemption, Thomas Gordon says CMS has already said it will not penalize providers who are struggling with the implementation if they can show they've acted in good faith.

"However, if don't do anything and you don't prepare, they aren't going to," she says.
Thomas Gordon says about 50% of the approximately 68,000 new codes under ICD-10 are "lateralities."

"Left or right. Most physicians know that. It's 'did you break the right or left hip,'" she says. "As far as the remainder, physicians are just going to have to know their specialty. Doctors will become familiar with their areas."

Thomas Gordon was asked to predict how the ICD-10 launch will go on Oct. 1.

"For those who've prepared it won't be that hard," she says. "If people are waiting until the last minute and thinking there will be an extension, they will struggle more."

"It would be naïve to say that people shouldn't prepare, but it would also be naïve to say that there won't be a few bumps or that they don't need to monitor after the fact," she says. "It's like when you put in a new computer system. You get used to it, you tweak and adjust and go back and do some retraining. After a while people forget they even changed. Is it overnight? No. It won't be so smooth that people don't have to pay attention."

See Also:
Four ICD-10 Fears, Decoded
GAO Outlook for ICD-10 Raises Questions
Physicians' ICD-10 Fears Unfounded, Says AHIMA
AMA Pushes for More Delay, But ICD-10 is Necessary