Health Information Management

Should there be a code freeze prior to ICD-10?

JustCoding News: Inpatient, June 9, 2010

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The go-live date for ICD-10 is October 1, 2013. That is one date you can mark on your calendar with 100% certainty. What is less clear, however, is whether CMS will impose a code freeze for both ICD-9 and ICD-10 prior to the go-live date to ease the transition, and if so when this freeze will take effect.

In the inpatient prospective payment system (IPPS) proposed rule for fiscal year (FY) 2011, CMS states:

We welcome additional input on having the last regular code updates to ICD-9-CM and ICD-10 on October 1, 2011, and to only add codes for new technologies and diseases on October 1, 2012 and 2013. We also welcome additional input on having the next regular update to ICD-10 occur again on October 1, 2014.

The main purpose of a code freeze would be so that providers, payers, clearinghouses, and health information technology vendors don’t have to simultaneously keep pace with code updates while also reconfiguring their existing systems for ICD-10-CM/PCS.

“Over the next few years, there is an incredible amount of work to do to get ready for ICD-10, and we don’t need to complicate the whole process by throwing in changes to the codes,” says Sue Bowman, RHIA, CCS, director of coding policy and compliance for the American Health Information Management Association in Chicago.

This transition not only affects coders, but it also has a pervasive impact throughout a healthcare organization, affecting many business processes Bowman adds. While the healthcare industry is currently used to handling annual code set modifications, preparation for a transition to an entirely new code set is a much larger and more complex endeavor. Incorporating additional code set modifications during the final stages of ICD-10-CM/PCS implementation preparation adds further cost and complexity.

Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of business and member development for the American Academy of Professional Coders (AAPC) in Salt Lake City, agrees. “[A code freeze] allows coders, physicians, and facilities to learn the new code set without having multiple changes along the way,” she says. “Just this year alone, there were close to a couple thousand ICD-10 code changes. If providers have to learn one set of rules and then relearn the rules, it will put a larger stress on them.”

Examine the pros and cons

A primary benefit of a code freeze is the ability to have a stable coding system that people can work off to develop software products, training materials, and coding products, Bowman says. “We’ve heard vendors say they haven’t done a lot yet because they’re waiting for that stable system. They don’t want to have to do all this work with a moving target,” she adds.

CMS states in the IPPS proposed rule:

We agree with commenters that there is a need to provide the provider, payer, and vendor community time to prepare for the implementation of ICD-10 and the accompanying system and product updates. The vendor community is especially interested in providing a more stable code set for ICD-10 while they are developing new products.

However, some disagree with the notion that any potential inconvenience should dictate the implementation or timing of a code freeze.

“Who is ICD-10 supposed to serve? Does ICD-10 serve the coder or software vendor? No, it’s supposed to serve the provider of care—facilities and hospitals—so they can accurately represent their patients’ conditions without having to clinically abstract the record,” says James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Atlanta.

Various organizations are increasingly using ICD-9 and ICD-10 coded administrative data to measure physician and hospital performance (e.g., California’s Office of Statewide Health Planning and Development, Medicare HospitalCompare). Some who are concerned about this ripple effect argue that ICD-9 and currently ICD-10 are not robust enough to accurately measure or portray patients’ clinical characteristics that predict these measurable outcomes.

For example, take the debate of acute kidney injury (AKI) going from an MCC to a CC in MS-DRGs, partially because ICD-9 and ICD-10 have not employed the differing stages of AKI to account for the increased resource utilization in higher grade disease, Kennedy says.

In addition, both ICD-9 and ICD-10 do not specify the number and location of atherosclerotic coronary artery disease, a known determinant of risk-adjusted outcomes. “If these codes will be frozen until FY 2015, then we will have gone two or three years without improving code sets to account for necessary specificity that is integral to hospital profiling and value-based purchasing,” says Kennedy, who adds that he does understand the need for a code freeze for only one year, but not two years, in anticipation of the October 1, 2013 implementation date.

“A code freeze would compromise the code sets’ ability to do what they’re intended to do—to substitute for clinical abstraction of a record,” Kennedy says. “We’re in essence freezing the shortcomings of ICD-10, which many physicians believe to not be perfect. There are still concepts in ICD-10 that have carried over the faults imbedded in ICD-9.”

Kennedy emphasizes the point that Medicare is in the throes of developing and implementing value-based purchasing, which will require a refined ICD-10 methodology, and it must also increase its emphasis on measuring physician efficiency as part of healthcare reform. Once the Institute of Medicine reports later this year how hospital and physician reimbursement will rely upon coded administrative data, physicians will demand that this data accurately support the severity of illness that they document in their records, Kennedy says.

“To wait until 2013 to make any changes, which then won’t be implemented until 2014 is short-sighted,” he says. “If on one hand they’re talking about efficiency but then freezing the methodology by which patients are categorized, it’s setting in stone the ‘garbage in garbage out’ phenomenon that the code sets currently in place are not capable of precisely defining patients’ conditions.”

And although CMS proposed to allow for limited updates for new technology and diseases during the freeze period, questions emerge regarding what qualifies as an emergent need and who determines which updates are necessary.

Some who don’t support a code set freeze argue that the industry is accustomed to annual code changes, so to continue updates wouldn’t necessarily mean a significant disruption.

“But they haven’t had to do it at the same time as implementing a gigantic change to the healthcare system that has been compared to Y2K and HIPAA,” says Bowman. Handling code updates on top of this enormous transition would make the implementation of ICD-10 more complicated than it needs to be, she adds. She noted that CMS’ proposal would allow for a limited update as needed for new diseases and technologies.

The AHIMA agrees with having a limited update for October 2012, but the association doesn’t support any kind of an update for October 2013.

“There are bound to be glitches on go-live date, and if changes to the ICD-10 code sets are allowed at the same time, pinpointing the source of any problems could be more complicated. Also, even seemingly small changes to a code set can have a big impact and require a significant amount of work to implement. For example, if a new value is created for one of the ICD-10-PCS characters, this change could affect hundreds of codes,” Bowman says.

Submit comments by June deadline

CMS must receive comments on the IPPS proposed rule no later than June 18, 2010, at 5 p.m. EST.

Providers who are still undecided regarding whether they support a code freeze should consider the transition to ICD-10 not only from an internal standpoint of learning the code set changes, but also in terms of what tasks they must complete with vendors, says Buckholtz of the AAPC, which supports the proposed code freeze. “They need to decide whether they feel that they can handle constant updates to two code sets up until implementation,” she adds.

“There’s still time for people to weigh in on this issue, so I encourage them to fully think about the impact on all sides and to consider the pros and cons,” Bowman says. “If they have any thoughts on revisions they would like to see made to the code sets, now is the time to get them in. That way it doesn’t have to be something that waits until 2014.”

Bowman adds that she believes it’s more important to propose any necessary revisions for ICD-10 than ICD-9. “Some people are looking at the freeze of two code sets as equal, but the life of ICD-9 is winding down. Many of the [ICD-9] codes that go into effect every year are intended to increase detail and specificity, but there are still existing codes to use for capturing these conditions and procedures and the need to expand ICD-9-CM will decline as the life of any newly created codes gets shorter.”

Submit electronic comments about the code freeze debate as well as other aspects of the IPPS proposed rule at the Regulations.gov website. Follow the instructions for "Comment or Submission," and enter the file code CMS-1498-P to submit comments on this proposed rule.

Editor’s note: E-mail your questions to Managing Editor Doreen V. Bentley, CPC-A, at dbentley@hcpro.com.



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