ICD-10: A Bad Moon Rising?

This post originally appeared at The RAConteur.

I drove into the office this morning at about 6 a.m. CDT under a "blue moon," which was strangely bright pink in color. A second full moon in a calendar month is indeed a rare event, and in the spirit of rare occurrences, I was hoping to share with the reading audience an idea or two to inspire and to cause a general feeling of uplift. Alas, thanks to recent events, I’m back in the darkroom developing a much different picture.

As someone who has the ability to think critically, it is becoming far too easy to pick on the country of my birth. There is a common metaphor, "top of the heap," that is used to describe someone who has succeeded beyond all others in life. With each passing day, when applying this standard to modern America, I have come to realize that whoever that happens to be at the top of the heap is standing atop rubbish, combining equal parts of the remains of our national intellect and the broken remnants of useless and poisonous products sold at Wal-Mart. It would be enough if it was simply a matter of slow-motion national degradation, but our situation is little aided by a prevailing attitude of not wanting to seriously repair the damage.

With the release of ICD-10 Final Rule II: Electric Boogaloo last week, CMS and the federal government, acting as the default gatekeepers of our excuse for a healthcare system, decided not only that the work of the past is the only endeavor worth defending, but that the future of healthcare reporting in this country is something that can't even be debated by those in the corridors of power.

I refer you to page 100 (nice round number!) of the above-linked document, where we discuss the comments offered on "Option 3," that being skipping ICD-10 altogether and waiting for ICD-11. To review, the latter is scheduled for release by the World Health Organization a mere eight months after the absolutely final implementation date of Oct. 1, 2014 mandated in this most ill-conceived of sequels.

According to CMS, Option 3 was eliminated due to "subject matter experts" estimating that "it would take anywhere from five to seven years for the United States to develop its own ICD-11-CM and ICD-11-PCS versions." At the end of that sentence is a footnote referring to one article that makes that point. Someone needs to tell CMS that the word "experts" denotes more than one.

On page 101, we learn that "one commenter pointed out that, if ICD-11, as scheduled for release by the WHO, should be accepted without further modifications as the reporting standard for the U.S., ICD-11 could be ready for adoption before the 2020-2022 date estimated in the April 2012 proposed rule." I now signify my knowledge of the identity of this particular commenter by jumping up and down, waving the foam "#1" on my left hand and activating a shrill air horn with my right hand.

CMS' response was to "recognize that there is a debate within the healthcare industry as to the value of ICD-10 compared to ICD-11." After that grudging recognition, the rule goes into a paragraph-long explanation of how setting aside ICD-10 would be expensive, with the completely random number of $22 billion in costs appearing for the first time in any form. As a point of reference, we have spent roughly $758 billion dollars on the Iraq War since its inception in 2003, and as far as I can tell, those dollars have yet to pay long-term dividends to the nation's healthcare system.

Left out of the Option 3 comments in the final final rule was the second half of my formal comment to CMS on the then-proposed rule. CMS is slowly turning the ship toward a model that rewards clinical outcome rather than volume of service. In this setting, it continues to make little sense to practice the slavish devotion to preserving our current payment model, as ICD-10 most certainly will. Designed in the late 1980s (which predates the wide public adoption of the Internet in this country), the American clinical modification of ICD-10 was designed with input from insurance companies, which goes a long way in explaining why 60 percent of the code set is devoted to accident descriptions. If there was no compelling actuarial interest in a code set being designed in this fashion, ICD-10 in its current form never would have seen the light of day.

CMS centered the bulk of their argument for ICD-11 rejection around costs. I challenge them to take a good look at that cost again. Medicare's current funding and payment methodologies are about as fiscally sound as those of Enron. If CMS had been serious about putting forth a paradigm shift in the payment model for services, ICD-10 shouldn't even be in the picture. If CMS is so worried about costs, they should take a minute to listen closely to hospitals across the country, currently suffering a slow death by administrative burden thanks to CMS' Recovery Audit process, which is in existence to "preserve the Trust Fund." I predict that the Medicare Trust Fund will be fine if there are no hospitals left to reimburse for services, which based on mounting evidence is CMS' long-term goal.

Blue moons in the late-summer sky are indeed rare sights. One would have hoped that bureaucratic myopia would be rarer still, but this is America we're talking about. Once again, the clunky and soon-to-be-obsolete has been embraced as state-of-the-art. Tonight, we can gaze upon the blue moon from a slightly higher point, for CMS just threw another 208 pages of garbage on top of the heap.

J. Paul Spencer is the compliance officer for Fi-Med Management, a national physician practice financial management company based in Wauwatosa, Wis. Paul has more than 20 years of experience across all facets of healthcare billing, including six years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.

More Articles on ICD-10:

HHS Finalizes One-Year Delay of ICD-10 to 2014

How Should Small Hospitals Prepare for ICD-10?

13 Questions Hospitals Should Ask About ICD-10 and Medical Necessity

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