Retire ICD-9 Before it Turns 40

ICD-9, envisioned in 1975 and oblivious to all that has occurred in the ensuing 39 years of medicine, needs to go. Everyone in healthcare knows it.

This weekend, in a park in Palo Alto, California, TCP/IP will have its 40th birthday party. The communications protocol that undergirds the Internet is just a few years younger than ICD-9, the ninth revision of the International Classification of Diseases.

ICD-9, envisioned in 1975 and oblivious to all that has occurred in the ensuing 39 years of medicine, needs to go. Everyone in healthcare knows it. Last week, CMS once again tried to put a stake in the ground, announcing its intent to publish a rule that implements ICD-10 for billing codes on October 1, 2015.

And yet, at the same time, CMS called off long-planned ICD-10 testing over the summer to let providers, billing companies, and clearinghouses a chance to see if CMS can accept their ICD-10-coded claims even though numerous providers want the testing to go forward as scheduled, and extended to a much wider range of participants.

The whole thing resembles that classic Peanuts comic strip where Lucy invites Charlie Brown to kick the football, only to snatch it away at the last minute, leaving poor Chuck flat on the ground in pain.

"I was hoping to have it done," says Linda Reed, vice president and CIO of Atlantic Health System in New Jersey. "We had a lot of things already in the pipeline. I just wanted to put it behind us. A lot of organizations, us included, did put a significant amount of money into the getting ready…"

We had training already, she continues, "we had training schedules, and we had made commitments with companies who were going to come out and do some training. We had a coder strategy. So there were some resources already put into that which we're going to have to now kind of slow down and then ramp up again in '15."

AMA: ICD-10 'An Unfunded Mandate'
Contrast that posture of readiness with the continuing stance of the American Medical Association—to the AMA, ICD-10 is just an annoyance it wishes would go away.

"The AMA has long considered ICD-10 to be an unfunded mandate that comes at a time when physicians are being asked to make a number of other significant changes to their practices," says AMA president Ardis Dee Hoven, MD.

"While the AMA did not support the legislation that extended the ICD-10 deadline because it failed to reform Medicare's flawed payment formula, we believe a delay would have been inevitable for a coding system that has not completed end-to-end testing. The postponement will give physicians extra time to work with vendors on necessary system updates, train their staff, and test the ICD-10 changes with payers, clearinghouses and others."

Even ICD-10 stalwarts such as Reed concede that extra time will be useful to some. "I know that our health information medical records people are probably relieved, because there was a lot to do in a little bit of time," she says. "One good thing is a lot of organizations did go out and start looking at some computer-assisted coding products, which should help. For some folks now it's going to give you some additional time to get those things in and work with them."

Atlantic Health selected such technology from Nuance and will be implementing it in the next year, Reed says.

As bad as things are, the damage from the SGR fix-spawned ICD-10 delay would have been worse if any more time had elapsed. "Whether you have three months or whether you have a year and three months, you'll wait until you have two months" to train coders and physicians, Reed says.

Unfortunately we haven't heard the last of the ICD-10 holdouts. The CMS NPRM spelling out the new ICD-10 date of 10/1/15 may seem like a formality, but it allows all manner of objections to be raised once again by the AMA and others.

CHIME CEO Weighs In
Kudos to those organizations which are going ahead with ICD-10 anyway. Their numbers are growing, according to CHIME president and CEO Russ Branzell.

"Most of our organizations essentially don't take their foot off the pedal, because if it really is October 1 of next year, then there's no reason for them to slow down" Branzell says. "Mainly because they've already installed the software. In some cases, their related software only works on ICD-10. There's really not a lot of choice in the matter."

"Now we do another year's work, people advance even more," he says. "They've built all their supporting systems, research, academic profiling, all the things they need to do, and it gets delayed again? What does that tell the industry?... That's very concerning."

CHIME and the 50+ organizations, including AHIMA and many payers, who urged CMS to proclaim October 1, 2015 as the new go-live date will not be caught napping again. Vigilance will be the watchword.

"We will go on an aggressive path for the next 15 months to ensure that there really is no way for this to occur again," Branzell says.

Two prominent EHR vendors also need to get their ICD-10 compliance in order and now have the chance to do so, Branzell says. While he will not name them, their installed base represents 5 to 10 percent of CHIME's membership.

Test for Worst-case Scenario
Now that the coalition of ICD-10 supporters has coalesced, I suggest they not wait too long to press their case. A good place to start would be to move up CMS's new delayed testing schedule to this fall, catch the momentum that had been building for testing already this summer, and broaden that testing to all comers, including those two holdout EHR vendors.

We need not look any further than last year's healthcare.gov debacle for the imperative to test early and often.

"What's absolutely a standard within the CIO community is, you test for worst-case scenario, not for best-case scenario," Branzell says.

We won't get this chance again to get ICD-10 right. If the healthcare industry can succeed in holding Congress and the government to the October 2015 date, and it ends up going badly anyway, healthcare will have no one but itself to blame as ICD-9 celebrates its 40th anniversary.