"To think we can implement this huge undertaking all on one day is simply ridiculous," says the former president of the Medical Association of the State of Alabama.
This is the first in a two-part series on physician concerns about ICD-10.
Physician groups have led much of the resistance against ICD-10 implementation. At its June Delegates meeting, the American Medical Association approved a resolution from W. Jeff Terry, MD, for a two-year grace period to protect physicians from errors and mistakes related to the code set.
W. Jeff Terry, MD |
Terry also authored an AMA resolution to delay ICD-10 in November 2011 which led to postponing implementation until October 1, 2014. Terry has practiced urology in Mobile, Alabama, since 1985 and has served as president of the Medical Association of the State of Alabama, president of the Alabama Urology Society, president of the Mobile Young Physician Society, and chairman of the Alabama Independent Physicians Association.
A delegate to the AMA since 1995, Terry has served on the AMA Council on Medical Service, and has been chairman of the Alabama delegation to the AMA since 2008.
In February, Terry gave testimony for the American Urological Association to the House Energy and Commerce Subcommittee on Health and was the only physician out of seven witnesses to testify against the implementation of ICD-10.
In a recent interview with Briefings on APCs, Terry shared his views on the challenges facing physicians in implementing ICD-10, and what types of errors his resolution would cover. His opinions do not necessarily represent those of the AMA or other physicians.
Q: What are the specific challenges physicians face with ICD-10 implementation in terms of technology, documentation, and coding?
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A: This is a huge question.
Technology—Some physicians have not even implemented an electronic medical record [system] yet. Remember, we are physicians and our primary interest and concern is the patient and his or her care, not an ICD-10 code that has nothing to do with the care of the patient.
Physicians who have implemented an EMR must hope that their EMR vendor will update their system to deal with ICD-10. This may be part of the contract, or the EMR vendor may charge the physician a large fee to make this update. Physicians don’t make the technology; we purchase it and what we are able to do depends on the product we purchase. We have no ability to change it.
There is a large cost to the physician, which has been well documented. The average physician cost at The Cleveland Clinic as of February 2015 for their implementation was $40,000 per physician. Not many of us have that kind of money laying around to put into a product that will not help in the care of our patients, will make our practices less efficient, and will make it harder for patients to get the care they need.
Documentation—We will not really know about this until we implement ICD-10 and then have the insurance companies deny our care in order to know how much documentation will be needed. Physicians document appropriately in order to take care of the patient. It is an entirely different situation as far as how we must document in order to support an ICD-10 code and get paid.
If I document “urosepsis” in the hospital, every physician knows exactly what I am talking about. This is a patient who has a urinary tract infection so badly that it got into his or her bloodstream. Patients can die from this and it takes aggressive treatment to cure these patients.
Well, the insurance companies and Medicare will not accept “urosepsis” in the new ICD-10 system. You must say in the medical record, “urinary tract infection with septicemia.” It is a big game for these folks, as well as the coders. It is a game that allows them to take payments away from physicians for care given and it has nothing to do with the quality of the care. We have used the term “urosepsis” for more than 100 years and now it is not acceptable in ICD-10.
Another example is a surgical operation I do called a TURP (transurethral resection of the prostate). We've also used this term for more than 100 years. It is found in medical textbooks and is a standard term for this surgical procedure.
Now in ICD-10, this will not be accepted. I must say TUEP or transurethral excision of the prostate. If I don’t use this term, then they will not pay me or will take payment back on review. If I use TURP and they do pay me, then the Recovery Auditors can charge me with fraud for improper billing. It all hinges on the words I use and not the care I give.
These are just two examples that I know about. There are thousands of other examples like this in ICD-10 that I do not know about and the insurance companies will just be waiting on me to make a coding mistake.
Why has this happened? There are four cooperating parties in control of ICD-10: AHIMA, CMS, the Centers for Disease Control and Prevention, and the AHA. You do not see a physician organization in that group. All of these folks will make money from the new ICD-10 system at the expense of physicians and patients. I have never heard one of these groups state their conflict of interest in this debate.
Coding—I have discussed this somewhat in the above statement. In our offices it will slow us down tremendously trying to find the correct code. There are 250 codes for diabetes. Physicians are individuals who want to get it right and who want to do a good job. They may honestly choose two or three different codes for diabetes in the same patient on different encounters and then the insurance company will want to know why. The hospital coders will be calling the doctors to be sure the codes match up and this will take time.
The coding industry has done studies documenting that it will take their coders a lot more time to do the hospital coding and they have also documented that having several coders code the same record can result in different codes.
If ICD-10 is so specific that the coding experts don’t agree, then how in the world are the physicians going to get it right? If ICD-10 was just used for statistics and epidemiological data as it was designed and intended, it would not be a big deal if we were off slightly in our coding. The problem is that we have made the ICD system part of our billing system and therefore any small mistake is a big deal for physicians. It should not be this way.
Q: What type of support do you believe CMS should offer physicians in order to aid them?
A: The best support would be to uncouple diagnosis codes from procedure codes as a recent Heritage Foundation study recommended. The AMA policy is to ask for a grace period. The exact definition of a grace period has not been decided, however a grace period should be designed to allow physicians to begin using ICD-10 on October 1 as planned, but not be subjected to penalties for coding wrong. They should be paid even if the computers don’t work properly, as they didn’t work on October 1, 2013, with implementation of the ACA exchanges and healthcare.gov.
It simply is illogical and defies common sense to think that a physician can dedicate himself or herself over a year-long period with time and financial resources to prepare for a product that will not help in the care of patients and will make practices less efficient.
To think we can implement this huge undertaking all on one day is simply ridiculous. Apparently CMS understands this, since it has told physicians to have enough savings to continue their practices for three to four months to get through the transition. They would never pass a law for any other part of our society and tell people they will need three to four months of savings to get through the transition or go out of business.
Pro ICD-10 folks say that we have had two years to get ready, but again, that is ridiculous. It is like telling a physician he will have to run a 5-minute mile in order to stay in business, but we are going to give you two years to do it.
Some things just can’t be done. It is like telling someone they need to learn to fly a plane and they will be given books and computer stuff to learn from. On October 1, they will be put in the cockpit with 200 passengers onboard and told to take off without ever having a dry run or practice flight.
Physicians need to implement ICD-10 and work with it in order to learn it and not be subject to penalties during this difficult process.
Q: Your resolution, and Rep. Gary Palmer's bill, want to protect physicians from "errors, mistakes, and/or malfunctions of the system." How do you define an error? Does it mean an unspecified code when more information is available, or any incorrect code (e.g., I02.0, rheumatic chorea with heart involvement, instead of J02.0, streptococcal pharyngitis)?
A: The resolution speaks of a grace period to protect physicians from “errors, mistakes, malfunctions.” As I said above, the exact definition of a grace period has not been decided and this will probably be done between CMS and the AMA.
It could be a complete uncoupling of diagnosis and procedure codes, or most likely it will be something like getting in the ballpark and not the very specific code. Perhaps if you just code for diabetes, that should be OK, instead of having to go through the 250 different codes.
Q: Rep. Palmer's bill also calls for a Government Accountability Office study on ICD-10 to be released by April 1, 2016. If providers are given a grace period while this information is being collected, do you believe the GAO will be able to create a meaningful report?
A: Yes. The GAO report will not be about the grace period. That will be enacted October 1. There are other unintended consequences of this implementation and other important concepts that need to be looked at by an unbiased committee to do the right thing.
Here are some things that need to be looked at:
- How changing the coding system on October 1 will impact reporting of quality measures and subsequent penalties that physicians will receive just because of making this transition
- How ICD-10 implementation will affect patients’ access to care
- How it changes physician practice patterns, such as early retirement and leaving private practice for academic or employed settings
- How it impacts physician productivity
- Asking payers to publish their ICD-9 to ICD-10 crosswalks so physicians can better understand payer rules so the ICD system does not turn into a guessing game
- Loosening ICD-10 documentation requirements so that a competent coder can clinically interpret the medical record within reasonable parameters and assign an appropriate and defendable code, thus preventing a payer or Recovery Auditor from denying payment when the circumstances are obvious, such as in my example of urosepsis
- Making future meetings of the Clinical Coding Advisory Committee public
- Evaluate adding a fifth Cooperating Party to consist of physicians appointed by the AMA with equal power of the current four Cooperating Parties (CMS, CDC, AHIMA, AHA) in the planning, interpretation and deployment of present and future ICD coding systems
- Evaluate uncoupling diagnosis codes from procedures codes, since we are the only country that does this
I am sure there are many others.
Q: Providers have known about ICD-10 since 2009 and cited uncertainty around implementation as one of the main deterrents to preparation. Do you believe a two-year grace period will be sufficient to prepare them?
A: Yes. Remember this will be a two-year period where physicians will actually be using the ICD-10 coding system and learning how to do it. That is totally different from saying, "You have two years to learn, but we are not going to let you practice or do it in real time until October 2015. If you don’t get it right, we are going to put you out of business."
It has not just been the uncertainty around implementation, but the uncertainty of not knowing what to do or how to do it. As Rep. Nancy Pelosi (D-CA) said, “You have to pass the bill to know what is in it.” I say you have to actually implement ICD-10 in order to know how it works and how to use it appropriately. It takes time.
Q: An AMA study said going straight to ICD-11 would be more disruptive than going to ICD-10 first, plus the code set would likely not be ready for many years. However, AMA has recently suggested going straight to ICD-11. What are your thoughts on going straight to ICD-11?
A: The study you are quoting is Board of Trustees Informational report 25 from the AMA annual meeting of 2013, “Evaluation of ICD-11 as a new diagnostic coding system.” This report was never adopted by our AMA house of delegates. In fact, it was voted down because the AMA delegates did not agree with the report and it was referred back to the board.
It is dishonest for the pro-ICD-10 folks to use this report and say it is AMA policy when it is not. The report was voted down because it was poorly done, incomplete, and not accurate. You can go to: [the AMA document] and look at item 35, where you will see that it was referred and not adopted.
My opinion of ICD-11 is also the opinion of the Association of Medical Directors of Information Systems (AMDIS), an association of Chief Medical Information Officers (CMIOs), and other healthcare IT leaders throughout America.
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ICD-11 is probably more complicated in some aspects, but also more clinically oriented in other aspects. It uses a coding system called SNOMED CT®, which I don’t understand. It is designed to be used in the EMR era, while ICD-10 was developed in the pre-electronic era. Putting politics aside, AMDIS feels that it would be best to skip ICD-10 because ICD-11 will ultimately be better and the rest of the world will be moving to this in 2017. Once again, there are still many uncertainties, and that is why the AMA study was not accurate and should not be quoted.
Q: At the AMA Annual Meeting, the Oklahoma delegation reportedly proposed a physician boycott of ICD-10. What are your thoughts on a boycott, and do you think some physicians will decide to do so?
A: Give me a break. When is the last time physicians boycotted anything? First of all, we are not going to do anything that hurts the patient and second, almost any organized boycott in medicine, if it has anything to do with payment, will result in an antitrust lawsuit.
If we did decide to boycott ICD-10 (if you mean just not using the code and not withholding patient care), then we would not be paid and could not stay in business very long.
If we decided to not use ICD-10 and just go to a cash practice where you don’t need to code anything (some physicians plan to do this) then you have another problem. You can’t take Medicare or Blue Cross Blue Shield September 30 and then not take it and charge the patient October 1. Physicians have contractual obligations with these entities and it may take six months to get out of these contracts (six months of no payments).
Q: Your resolution also asks the AMA to help prepare providers to institute cash-only practices if they choose not to use ICD-10. What would some of the advantages be to moving to a cash-only practice and do you think it would impact cash flow? Do you believe this would have an impact on patients in rural areas who don't have other options for providers?
A: This is partially answered in the previous question. Only certain types of practices can go to cash-only practices. Any physician that uses the hospital would not be able to do this because not many folks can afford these bills without insurance.
Primary care physicians or physicians who only work in their offices can probably do this, and do it well with improved patient care and efficiencies. Cost of care most likely will actually go down. Again, if you have contracts in place, you can’t just convert to a cash practice all on one day. I wanted the AMA to look into this problem and help advise physicians who wanted to do this.
Q: A separate resolution called for the AMA to become a member of the Cooperating Parties responsible for the codes. What do you think being a member will do to help physicians?
A: Don’t you think it fair to have physicians on the board so to speak of a business that controls our profession to such an extent that ICD-10 controls us? If we had been at the table, perhaps the coders could use some common sense in their coding of our services, which in the current system they do not.
Q: You testified as a representative of the American Urological Society during a February Congressional subcommittee hearing that the number of ICD-10 codes is difficult for physicians to handle, though specialty societies such as the AUS have proposed hundreds of new codes for the first update. What kind of compromise can be reached so that ICD-10 is specific enough for physicians but not overwhelming?
A: A compromise developed by physicians being a fifth cooperating party of the ICD system would have helped, however there is no way to go back in time. I don’t see any way to do a compromise in the ICD-10 coding system at this time.
When ICD-10 was being transformed into the US clinical modification (ICD-10-CM), all physician specialties were asked to submit codes. Once again, it is the nature of physicians to be complete and try to cover all bases, so thousands of codes were sent in to the ICD-10 committee.
The problem is that these physician organizations did not understand how ultimately the ICD-10-CM coding system would be put together and how it would negatively affect the care we provide. Physicians simply were not involved at all in the ultimate product that got thrown on our profession.
It is said that as a urologist I only have to know less than 100 codes and that I should not worry about it. These are folks making statements who do not take care of patients and who do not have to deal with insurance companies.
In Alabama, our primary insurance company is BCBS, with 90% of the business in our state. They are making plans and have been having meetings across our state for the past year in order to have physicians code up to 10 diagnostic codes per patient encounter. They are doing this because it will benefit their company to have all of these codes to better classify the patients as far as severity of illness.
What this means to me is that if I see a patient with a kidney stone, diabetes, heart disease, high blood pressure, dementia, and high cholesterol, I cannot just code for the kidney stone. I must code for all the other medical problems as well and I am simply not qualified to do this with accuracy for diseases that I don’t treat. I have no idea how I will handle this when BCBS makes us do this.
My point is that even as a specialist physician I must know about the whole patient if I am going to take care of that patient appropriately. When I am told that I only need to know the urology codes, then my response is that you have no idea about what I do and you have no idea about the practice of medicine, how to take care of patients, and how we have to interact with the various insurance companies who all have different rules and regulations dealing with how we get paid for our services.
Steven Andrews is editor of Briefings on APCs and outpatient editor of JustCoding.com.