AAFP Challenges Wisdom of Adopting ICD-10

The AAFP came out swinging recently against CMS' proposal for the adoption of the greatly expanded International Classification of Diseases, 10th Revision, Clinical Modification, or ICD-10-CM, for outpatient diagnosis coding.

AAFP Board Chair Jim King, M.D., of Selmer, Tenn., outlined the Academy's objections to CMS' proposed rule on the ICD-10 (38-page PDF; About PDFs) diagnosis coding in an Oct. 14 letter (6-page PDF; About PDFs) to CMS Acting Administrator Kerry Weems.

ICD-10 would replace the current International Classification of Diseases, 9th Revision, or ICD-9, code set that has been used in the United States since 1977. The proposed ICD-10 compliance deadline is Oct. 1, 2011.

King argued that CMS has not done its homework in assessing the impact of "the extreme overhaul of the current outpatient medical system required for the transition."

He said the "purported benefits" of CMS' proposal were "based on assumptions and not supported with any real world trial involving practicing physicians in the United States." King pointed out that U.S. physicians have been slammed with government mandates since 2000, each promising a simpler or better health care system, but physicians have seen little benefit.

"We fear that change fatigue and financial hardships are becoming chronic conditions common to the health care industry," said King.

If ICD-10 were adopted, the number of diagnosis codes would balloon from the current 13,500 to 68,000. King noted that while many physicians would use a small subset of the ICD-10 diagnosis codes, primary care physicians are among those specialists who would feel a significant impact due to the broad range of conditions and complaints they deal with in their practices.

A cost analysis of the proposed transition to ICD-10 was initiated by a coalition of organizations, including the AMA; the Medical Group Management Association, or MGMA; the American College of Physicians; the American Academy of Professional Coders, or AAPC; and other medical professional organizations. The resulting report, "The Impact of Implementation of ICD-10 on Physician Practices and Clinical Laboratories," (40-page PDF; About PDFs) recently was made public.

Researchers looked at a variety of practice sizes and estimated that the transition to ICD-10 would cost

The study noted that practices would accrue higher costs in a variety of areas, including staff education and training, information technology system changes, increased documentation, and cash flow disruption.

The report concluded that the implementation of ICD-10 would have a greater financial impact than some other high-profile federal mandates, including the National Provider Identifier number and the Health Insurance Portability and Accountability Act.

The authors noted that in addition to the stated one-time costs for practices of assorted sizes, physicians would incur permanent additional costs associated with more rigorous documentation that would increase each physician's workload by up to 4 percent.

MGMA President and CEO William Jessee, M.D., said in an interview with AAFP News Now that a rapid move to ICD-10 would "divert critical human and financial resources and would likely lead to massive and lengthy disruption to the claims payment process."

Jessee pointed to the current environment of financial turmoil, saying "Physicians are facing an increasing number of challenges related to declining reimbursement, increasing operating expenses and reduced capital expenditures. We're concerned that the federal government may move forward with mandating ICD-10 with an overly accelerated time frame, a move that would add additional cost and complexity for physicians."

Deborah Grider is credentialed as a certified coder though the AAPC and the American Health Information Management Association. She serves as president of the National Advisory Board of the AAPC.

Grider has devoted three years to researching what it would take to implement ICD-10 and has authored several books on the topic.

She acknowledged that the AAPC -- as well as the other organizations in the coalition that initiated the cost survey -- support the transition to ICD-10. Grider called ICD-9 "outdated."

"We've been adding diagnosis codes to ICD-9 since 1978 … and it's only geared for up to five digits of specificity. There's no more space to add any more digits," said Grider, adding that in ICD-10, users have up to seven digits.

Despite her support of ICD-10, Grider said HHS' time frame to adopt by 2011 was unrealistic. She called for a 2013 deadline.

"We have to move to ICD-10, but if we have four years, we can start planning and preparing," said Grider. She noted that all other major developed countries have already migrated to the system. However, she added, the United States would be the first country with a multi-payer health care system to use ICD-10.

As a coder who works directly with physician practices and payers, Grider is gravely concerned about the financial impact that a two-year implementation deadline would have on physicians.

She said in conversations she's had with some of the country's largest health insurance companies, she's heard this message repeatedly: "We won't be ready in two years; we can't be."

The impact on physicians' cash flow could be dramatic. "My fear is that on Oct. 1, 2011, no one's going to get paid and probably won't for the first six months after implementation of ICD-10," said Grider. "If you're not paid for six months, how do you keep your practice running?" she asked.

The Academy urged CMS to delay adoption of ICD-10 indefinitely. King asked CMS to realistically consider whether pressures to rapidly adopt the ICD-10 code set "outweigh the importance of supporting the already fragile backbone of patient care," namely, primary care medicine.