CMS calls for transition to ICD-10 codes in 3 years

Washington -- Physician organizations are concerned that a federal agency's proposal to implement an expanded set of diagnostic codes by Oct. 1, 2011, does not give doctors enough time to get up to speed. The deadline would occur only 18 months after national electronic transaction standards are upgraded to accept the new codes.

The Centers for Medicare & Medicaid Services, in an Aug. 22 proposed rule, called for physicians, hospitals and health plans to make the transition to the 10th revision of the International Classification of Diseases code sets standard. ICD-10 has roughly 65,000 diagnostic codes, about five times as many as ICD-9. Physicians use ICD codes to record patient diagnoses and Current Procedural Terminology codes to record the procedures they provide to patients. Hospitals use ICD for both coding processes.

Before physicians, hospitals and others can use the new code sets, they must upgrade their electronic transaction systems to be compatible. CMS, in a separate proposed rule, set an adoption deadline of April 1, 2010, for these transaction standards.

Dept. of Health and Human Services Secretary Michael Leavitt said the richer code sets of ICD-10 and the transaction upgrades will allow HHS to support full quality reporting, pay-for-performance and bio-surveillance. In contrast, ICD-9 is outdated, is too imprecise for modern medical care, and lacks the space needed to adapt to new procedures and technologies, he said.

Both the American Hospital Assn. and the American Health Information Management Assn., which represents health information professionals, support CMS' three-year implementation plan.

But Joseph M. Heyman, MD, chair of the AMA Board of Trustees, said putting into practice both the new coding system and the transaction standards by 2011 is asking too much from physicians. "CMS is setting the stage for major implementation problems."

William F. Jessee, MD, president and CEO of the Medical Group Management Assn., said CMS should not underestimate the difficulty of such a systemwide change. "Moving to these new code sets has the potential to be the most complex change for the U.S. health care system in decades."

America's Health Insurance Plans is also calling for more time. AHIP wants a two-year implementation for the electronic standards and an additional three years after that to make the transition to ICD-10 codes, said AHIP spokesman Robert Zirkelbach.

Test, then adopt

In less than three years, physicians who bill electronically would need to have electronic transaction software that can handle the upgrade. All physicians who take Medicare or private insurance would need to learn a new set of diagnostic codes that is often much more complex than the current system.

For example, a wrist injury with one ICD-9 code might have several ICD-10 codes that allow a physician to specify which wrist was injured, how severe the injury is and how the injury occurred. Also, some current codes have been condensed in ICD-10 or do not have an exact equivalent code in the new system.

Physicians would be able to use CPT codes to keep billing services as usual.

The AMA did not offer a preferred timeline to implement ICD-10 or the transaction standards. But Dr. Heyman said CMS should at least allow time for pilot-testing both systems separately instead of implementing them simultaneously.

Physicians and plans might have only a little more than a year to adopt the transaction standards before the April 1, 2010, deadline, even if CMS moves through the rule-making process quickly. Federal law requires the agency to provide 60-day comment periods for both the proposed and final versions of rules, which means the proposed ICD-10 and electronic transaction rules might not be finalized until early 2009.

Physicians will need much more than a year, said Robert Tennant, a senior policy adviser for the Medical Group Management Assn. "That's just outrageous. I don't think it can be done." MGMA supports delaying the transition to ICD-10 until the transaction standards have been tested and fully implemented.

The American College of Physicians believes CMS should not even move forward with ICD-10. "Our position has been that the benefits might not outweigh the costs at all," said Brett Baker, director of the ACP Regulatory Affairs Dept.

Small practices challenged

In the proposed rule, CMS estimates that implementing ICD-10 will cost all physician practices in the U.S. only about $138 million, or 0.4% of total practice revenues.

CMS expects payers and specialty societies will provide updated "superbills," which list commonly used codes, to help physicians adjust to the new system.

"We recognize that the transition to ICD-10 will require some up-front costs," said Acting CMS Administrator Kerry Weems. But every day that passes without the codes being used is a lost opportunity to measure more precisely the value of health care spending, he said.

While the full extent of the impact of ICD-10 and the new electronic transaction standards is difficult to predict, "it's certainly going to be a burden on the physicians," said the MGMA's Tennant. He said CMS likely underestimates the proposed rules' impact, particularly on small physician practices. Practices that do not have computers in exam rooms will take more time and have more difficulty adjusting to ICD-10 than hospitals and larger practices.