AMA Delegates and Oncologists Balk at ICD-10 Implementation

Caroline Helwick

March 2012, Vol 3, No 2 - Health Policy


New Orleans, LA—According to the American Medical Association (AMA) and many oncologists, the International Classification of Diseases, Tenth Revision (ICD-10) diagnostic coding system will be a needless and expensive burden to oncology practices, without enhancing patient care. ICD-10 is being developed by the World Health Organization. The Centers for Medicare & Medicaid Services (CMS) ordered the switch in 2009 as part of carrying out the Health Insur ance Portability and Accountability Act. At their 2011 interim meeting last fall, the House of Delegates of the AMA voted to "work vigorously" to stop the implementation of ICD-10 to "reduce its unnecessary and significant burdens on the practice of medicine." With that goal in mind, James L. Madara, MD, Executive Vice President and CEO of the AMA penned a letter to Health and Human Services (HHS) Secretary Kathleen Sebelius, MPA, on February 2. Citing the government's intention to streamline regulations, Dr Madara said that, "This is a perfect opportunity for HHS to make good on its commitment to improve the regulatory climate for physicians."

Dr Madara said that ICD-10 is something that will impact essentially all business processes within a physician's practice and will be a "massive administrative and financial undertaking for physicians." The timing, he said, "could not be worse," because physicians are in the midst of implementing electronic health records (EHRs) to avoid penalties. Should ICD-10 coincide with these efforts, Dr Madara predicted "physicians will be forced to close their Medicare patient panel or limit the number of Medicare patients they treat in order to minimize the aggregate financial and administrative blows to their practice due to unfunded regulatory mandates and the unfair penalty programs."

The AMA's efforts were successful in at least delaying the start date, which was previously set for October 2013. "We have heard from many in the provider community who have concerns about the administrative burdens" of ICD-10, Ms Sebelius wrote in her statement. She said the HHS will announce a new compliance deadline after reexamining the pace of implementing ICD-10. The HHS press release stated that, "ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world that has long been using ICD-10."

Expensive Move from ICD-9 to ICD-10
Delegates at the AMA interim meeting called the ICD-10 overly complex, burdensome to medical practices, expensive to implement, an obstacle to implementation of EHRs (with a more pressing deadline), and worthless in terms of patient care. The new version contains approximately 68,000 codes compared with only 14,000 codes in the ICD-9. But the complexity of ICD-10 coding extends beyond sheer volume. The new codes contain as many as 7 characters compared with a maximum of 5 in ICD-9. Mike Green, MD, a family physician in Macon, GA, said, "It doesn't take an expert in coding to review this and ask, 'Do we really need to know what kind of dog bit you to be able to code a dog bite?'" Implemention of ICD-10 is projected to cost $83,000 for a 3-physician office and $285,000 for a 10-person group. Several physicians predicted that this additional cost, and other financial fall out, could sink some marginal practices. "This will be used by every insurer in the country to deny payment, because with so many codes it's simple to say 'You coded this wrong.' At best, it will significantly delay payment," Dr Green predicted. "There are many practices in my area that run month to month. You interrupt the cash flow and the physician is either taking out a loan or closing his doors."

Oncologists Weigh In
Steven Vogl, MD, an oncologist who practices in Bronx, NY, was vehement in his disdain for the whole package. "I consider this more of the excrement heaped upon doctors, and it only makes it harder for us to take care of patients," he told Value-Based Cancer Care. "It costs us time, effort, and money to comply with such nonsense." The payers "keep cutting what they pay us, and then expect us to document more and spend more of our money doing so," he said. Regarding the "granularity" of ICD-10, which proponents say will foster quality care, Dr Vogl commented, "It will be absurdly detailed in ways that make no medical sense. And do I care if Egypt has the same coding system we have? No. But I do care that I will spend more time coding office visits. If my patient with bone cancer is limping, will it matter which corner of the bone is involved, or which corner of the breast the cancer started in?" Dr Vogl predicted that the additional complexity of coding will hinder oncologists' willingness to provide second opinions, which will cost more to document than will be reimbursed. Like Dr Green, he also feared there will be more claims denials and delays from insurance companies and CMS.

"This is bad for doctors, bad for patients, and good for the insurance companies," Dr Vogl concluded. Samuel M. Silver, MD, PhD, FACP, Director, Cancer Center Network Division of Hematology/Oncology, University of Michigan Health System, Ann Arbor, and Chair of the Subcommittee on Reimbursement for the American Society of Hematology (ASH), said that the delay in implementation was necessary. He also said that there was work to be done on improving the upcoming version of the coding system. "ASH has been concerned about ICD-10," said Dr Silver. Although the greater "granularity" of the codes may be reasonable for conditions that are managed surgically, such changes are not necessary in oncology. "We don't care if it's Hodgkin lymphoma of the left great toe. That kind of anatomic localization does not help us," Dr Silver pointed out. "But even more so, ASH has done 'crosswalk' studies between ICD-9 and ICD-10 and has found that for a number of our diseases, ICD-10 actually becomes less granular. It lumps things together that were more finely divided in ICD-9."

"This is important because hematologic diseases are getting more and more specific, especially with regard to therapeutics," he continued. "If CMS or any agency needs to determine that there has been a high quality of care and that therapy was appropriately delivered, having an understanding of this is an important part of advanced coding. If we are lumping rather than dividing, we lose granularity, and we may not know if the right drugs— which are very expensive—are being delivered."

Dr Silver agreed that physicians simply have too much on their plates right now. "We are dealing with huge electronic health record conversions and various quality initiatives. This onslaught of new codes will be another huge burden." Jeff Ward, MD, Chair-Elect of the American Society of Clinical Oncology's Clinical Practice Committee and part of a 9-person practice in Edmonds, WA, admitted to having "mixed feelings" about ICD-10. "As oncologists, we are looking forward to having a coding system that reflects modern medicine and terminology," he said. "On the other hand, we recognize that converting to a new system at the same time our whole practice system is rapidly changing is just one more thing that will be onerous and time-consuming for our practice staff and management." Dr Ward said that the terminology in the current coding system is woefully out of date. "The lymphoma nomenclature has changed 3 times since ICD-9 was started," he said. For example, "lymphosarcoma," a term that is no longer used, has a code; "mantle-cell lymphoma" and even "follicular lymphoma" do not. "We look forward to the day the changes are in place," Dr Ward said, "but we don't look forward to having to put the changes in place without a major increase in reimbursement for the cost this will entail, especially in a situation that is increasingly difficult from a financial standpoint."