Physicians push to delay move to new ICD code set

Washington -- Three years is not nearly enough time to move physicians to a new diagnostic coding system, the American Medical Association and several other groups say.

Health information technology legislation that the House started considering last month would require hospitals and physician offices to upgrade from the ICD-9 coding system to ICD-10 by October 2009. Using a much richer set of codes corresponding to patient conditions, health care professionals could more accurately diagnose medical problems and pass the information along to both public and private payers, supporters of the bill said.

Hospitals use ICD codes to record both the diagnosis of a patient and any medical procedures that he or she receives. Physician offices use the ICD system for the diagnosis phase but employ CPT codes to identify any procedures that they provide.

The timeline established by one version of the Health Information Technology Promotion Act of 2005 and backed by hospitals and device manufacturers is much too ambitious, according to physicians, health plans and practice managers. A coalition of these groups is calling for Congress to push back implementation from 2009 to 2012 to give doctors more time to get up to speed on the new system.

"In terms of health care transitions, this is incredibly fast, and it's just not doable," said Robert Tennant, senior policy advisor for the Medical Group Management Assn. "There are so many things that have to happen -- software upgrades, clinical and administrative staff training, crosswalks from the old code set to the new."

The AMA House of Delegates at its Annual Meeting last month in Chicago approved a resolution calling not only for a delayed implementation schedule but for a modified version of the new coding system that has a smaller number of entries. By some estimates, moving to the full version of ICD-10 would involve increasing the number of codes from 24,000 to about 207,000.

Delegates argued that physicians shouldn't be required to choose from all of those codes when making diagnoses.

"Many of those codes, quite frankly, I don't think are clinically very useful and are certainly going to cause a real problem," said Arthur Snow, MD, a family physician and alternate delegate from Kansas.

But the AMA stopped short of opposing the update altogether. Some physicians offered reasons why having a richer code set would be useful to many doctors, especially those dealing with children and other specific patient populations.

"We tend to try to make adult codes fit little people, and it doesn't work very well for us," said Melissa Garretson, MD, a Texas pediatrician and alternate delegate from the American Academy of Pediatrics. She agreed, however, that the proposed three-year timeframe for implementation would be too rapid for doctors.

Physician groups, including the AMA, successfully convinced lawmakers to preserve the CPT coding system used to bill for medical procedures in the office setting. But the need to utilize ICD codes for making patient diagnoses means that the change would affect physician practices nonetheless.

When a physician today diagnoses patients with ankle injuries, for instance, the doctor might be able to submit the same ICD code to each appropriate payer -- typically using a "superbill" that lays out some of the more commonly used codes as a handy reference. With the move to the more complex system, the physician might be required to locate and submit different codes depending on which ankle was affected, the severity of the problem and even how the injury occurred. The more specific codes will require physicians to gather more information during the diagnosis and to compile more detailed documentation than they do now.

Such greater complexity would be too much for physicians to learn adequately by October 2009, said Karen Ignagni, president and CEO of America's Health Insurance Plans. The migration to ICD-10 will require information technology overhauls and new electronic transfer standards throughout the system before doctors can even start becoming familiar with the actual codes, she said.

Some of the groups calling on Congress for more time worry that the majority of physicians whose practices have not gone electronic will have difficulty handling the larger system, leading to mass confusion and reimbursement delays. Some doctors' offices that are not fully modernized may not grasp the enormity of what they would face under a three-year timetable, they said.

"Physicians and other providers will need time to understand and prepare for the major change in their practices that will be called for by ICD-10," said Joseph Smith, senior vice president and chief information officer for Arkansas BlueCross BlueShield, in a recent appearance before a House subcommittee. "Unless physicians have the support systems in place to perform real-time coding while the patient is in the office, then we will not achieve any benefits from the greater specificity of ICD-10."

In a letter to House Republican leaders, 120 Democrats noted that the legislation would not provide any federal funding to help physicians purchase electronic record systems, effectively making the ICD switch an unfunded mandate.

Although physician groups have been focused in the past on heading off a possible move by Congress to replace the CPT system with ICD, doctors are starting to realize that the change will have a major effect on their lives even if CPT stays in place, said MGMA's Tennant. He added that the new AMA policy would go a long way toward making this clear to lawmakers. Physicians find themselves on different sides of the issue from hospitals and device manufacturers because doctors are facing relatively more disruptions under the more detailed system, Ignagni said.

The bill's positive side

Despite lodging concerns about this portion of the House bill, the AMA has declared its support for the legislation as a whole. The bill would establish safe harbors for health IT donations to physicians, implement uniform privacy and security standards for health information, and codify in statute the national health IT coordinator's office.

At press time, House negotiators were attempting to prepare the legislation for a floor vote by reconciling differences between two versions of the measure -- one that contains the ICD-10 update and one that omits the change. If the 2009 deadline remains in the bill and receives House approval, the AMA and other groups will still be able to lobby for a delay while lawmakers settle differences with the Senate-passed health IT bill, which would not affect the coding system at all. Supporters of the move to ICD-10, however, could try to find another legislative vehicle on which to move the provision.