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Will the Transition to ICD-10 Ultimately Improve Patient Care? Only Time Will Tell.

Denise M. Nash, MD, CCS, CIM
Vice President of Compliance and Education, MiraMed Global Services

Undoubtedly the International Classification of Diseases, Tenth Edition (ICD-10) is a more specific means of capturing diagnostic data. It allows not only for specificity of laterality, but it also allows capture of episode of care with the 7th character designation for initial, subsequent and sequelae. A recent study by the Heritage Foundation Report (HFR) entitled, The New Disease Classification (ICD-10): Doctors and Patients Will Pay1 provides a unique perspective about how ICD-10 will impact physicians and patients alike.

One of the things pointed out in the article is the abandonment of the current reimbursement system for newer models. I tend to concur from a financial perspective because the current system is cumbersome with many factorials built in, whether diagnosis-related group (DRG) based or ambulatory payment classification (APC) based or Medicare Physician Fee Schedule (MPFS). The episode of care bundled payment models currently being tested by Centers for Medicare and Medicaid Services (CMS) produces composite payments for a given diagnosis and procedure or a trigger point as the driver of the episode (diabetes, COPD, etc.). There are four payment models:

  1. Retrospective acute care hospital only
  2. Retrospective acute care hospital plus post-acute care
  3. Post-acute care only
  4. Acute care hospital stays only which were initiated on January 31, 2013

These models target alignment of incentives to produce better results. They then create strong incentives for hospitals and doctors to work together toward a single goal of more streamlined and coordinated care, while eliminating preventable complications and unnecessary services (medical necessity).

The most widely used are for orthopedic procedures such as hip and knee replacements. I agree with these models in theory, but models need to be totally tested for accuracy and disbursement feasibility. How many different specialties are involved in the care of a particular individual? Taking a hip replacement, for example, may involve a facility, all the pre-work including medical clearance, the anesthesiologist, the surgeon and all of the post-surgical work during the 90 day global. But how will the money be divvied? Who will hold the purse and be responsible for the accounting? Those questions need to be answered, especially if all participants are not part of the same network.

These reimbursement models tend to work in self-contained, integrated delivery systems or staff model health maintenance organizations (HMO). This brings up a second point in the article: that we are moving out of the single practitioner arena in order to survive the new emerging healthcare system. If we are moving to a new reimbursement schema, then the current way of practicing medicine will not work.

I travel throughout the country speaking to physicians about documentation to meet specificity. I can remember being out in the Midwest and speaking about congestive heart failure with systolic and/or diastolic failure. One physician spoke up and said that is all well and good, but our hospital does not have an echocardiogram and therefore that type of heart failure could not be specified.

Being from the eastern part of the United States (U.S.), I take it for granted that everyone has access to all healthcare technology, but in the case just cited this is, indeed, not the norm throughout the U.S. The other thing that physicians seem to echo, which was also evident in the article, is that moving to ICD-10 will affect their wallet.

They feel that ICD-10 will impact timely reimbursement even further. I was told by physicians recently that this is “just another method of nonpayment” and that the insurance carriers will be holding on to their funds even longer than currently witnessed.

Two years ago, I consulted with numerous healthcare facilities and expressed that they needed to establish a line of credit in order to meet payroll and any other short-term expenses during the ICD-10 go-live period. This is no different for a physician or a physician group. Everyone will feel the impact if not prepared for the aftershock. I also have heard that the expected productivity impact initially is thought to be 40 percent, however many healthcare consultants and providers estimate up to a 70 percent decrease for the initial 90 days and then stabilize at 50 percent. Will 50 percent be the new norm? Only time will tell. Will production ever return to current International Classification of Diseases, Ninth Edition (ICD-9) levels? The answer is a resounding no, as witnessed by the Canadian model which has never fully recovered since implementation in 2002.

Two years ago everyone was being told to find a coding vendor partner to help with the ICD-10 transition. As the article pointed out, some found vendors whereas others hired additional staff to meet the shortfall. As the article so aptly pointed out, ICD-10 will have an overwhelming impact on physician productivity. Currently hospitals place many inpatient charts in pended status until clearer documentation is obtained from the physician on diagnostic specificity. We will also witness this phenomenon with outpatient claims, especially those that must contain both the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) equivalent of the procedure code.

The rules for coding CPT tend to aggregate to a single procedure whereas the rules for Procedure Coding System (PCS) tend to de-aggregate, as in the example of a failed laparoscopic cholecystectomy converted to an open procedure. In CPT we code only code the definitive procedure and in PCS the coder must code the failed lap procedure as an inspection along with the resection of the gallbladder accomplished by the open procedure.

In the example above it would be wrong to code CPT 47562-53, discontinued laparoscopic cholecystectomy, and CPT 47600, open cholecystectomy, but in PCS the expectation is to code 0FT40ZZ, resection of gallbladder, open approach and 0FJ44ZZ, inspection of gallbladder, percutaneous endoscopic approach. Another example, if a patient is seen for a colonoscopy and 21 polyps are removed in CPT, you only code the procedure once, whereas in PCS all polypectomies would be reported.

This is extremely cumbersome for the coder because they need to wear two hats to code outpatient hospital procedures. Although guideline A11 in PCS states “Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Example: When the physician documents ‘partial resection’ the coder can independently correlate ‘partial resection’ to the root operation: Excision without querying the physician for clarification.” This guideline needs to be clearer, because if the surgeon does not document, then the coder is forced to pend the chart. In my opinion, since we were forging into ICD-10, we should have stuck with one methodology of surgical coding.

Most coders and surgeons are already familiar with CPT and the documentation required for surgical procedures. It would have been an easier more palatable transition to stick with something already familiar rather than go to a new system of surgical coding. Although I am not advocating for the AMA process, I honestly don’t understand the reason why we needed a separate surgical coding methodology for inpatient coding. PCS seems to have been adapted from the British OPCS Classification of Interventions and Procedures, Version 4 (OPCS-4), and, if not, they share many similarities.

As to the point that ICD-10 will improve patient care, this can be a valid point as retrospective analysis of data is done and best practices are formulated. However, there is a blurring on how exactly it will improve patient care.

Although there are many valid drawbacks to ICD-10 as pointed out by the Heritage report, I still see valid arguments for the implementation of ICD-10-CM. I am not sure that dual coding is the answer as this will have a deleterious impact on reimbursement and coders. However, as the article aptly points out, Medicaid is not yet ready for the conversion and that will additionally impact the system as dual coding will be necessary.


¹The Heritage Report: The New Disease Classification (ICD-10): Doctors and Patients Will Pay John Grimsley and John O’Shea, M.D.

Denise M. Nash, MD, CCS, CIM, serves as Vice President of Compliance and Education for MiraMed Global Services and as such she handles all compliance and education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value-based purchasing programs. Nash has past experience with episode of care data and patient management in the ACO environment. She has also worked with both hospitals and physician practices on the legal and financial aspects of adding new services to the respective facilities. Dr. Nash is a consultant on coding/compliance audits at physician practices, hospitals and has worked for insurance plans conducting second level appeals. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division. She can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..


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