Groups oppose complexity, cost of new coding system

Associations support single coding system

The Health Care Financing Administration (HCFA) heard an earful in mid-May about implementing the new procedure coding system for inpatients, the ICD-10-PCS. During a recent meeting of HCFA’s ICD-9-CM Coordination and Maintenance Committee, representatives from several health care organizations expressed reservations about the cost and the complexity of the system.

Under contract to HCFA, 3M Health Information Systems of Salt Lake City developed ICD-10-PCS as a potential replacement for the procedure codes, volume 3, of the International Classification of Diseases (ICD) codes, ninth edition (ICD-9). The National Center for Health Statistics is also revising a clinical modification (CM) of the World Health Organization’s ICD-10 classification. ICD-10-CM is planned to replace the ICD-9-CM, volumes 1 and 2. No implementation date has been set for either system.

In its testimony, the American Health Information Management Association (AHIMA) in Chicago called for the implementation of a single coding system. "If ICD-10-PCS goes into effect, the push for a single system will escalate because it will be apparent that we will have two highly specific systems with different codes for the same entities," said Linda L. Kloss, MA, RHIA, executive vice president and CEO of AHIMA. "The possibility of a single procedural coding system should be evaluated now so an informed national decision can be made about the best long-term solution for all health care settings, services, and payers." Kloss recommended that federally funded research evaluate the feasibility of moving to a single system. This research should examine:

• the efficacy of alternative systems across all health care settings, payer types, and health care services;

• the implementation and long-term cost and benefits of a single system compared to the implementation and long-term cost and benefits of operating multiple systems;

• a recommended strategy for implementation that takes into account the need to implement ICD-10-CM for diagnoses.

While AHIMA says ICD-10-PCS is a potential candidate as a single procedural coding system, the organization does not think the system has been adequately tested in all the areas that would be necessary for use beyond hospital inpatient services, Kloss stated.

AHA: Take steps before implementation

The American Hospital Association (AHA) in Chicago also called for extensive testing before the system is implemented. Before implementation takes place, the AHA wants the new system to be tested for all services in all settings, said Nelly Leon-Chisen, director of the central office on ICD-9-CM at the AHA. "Thus far the testing has been limited to primarily the medicine and surgery sections in the inpatient hospital setting." The testing also should consider the compatibility of the new system with existing payment systems, whether they are DRGs (diagnosis-related groups), APCs (ambulatory payment classifications), or simple fee schedules, she added.

The AHA maintains that the ICD-9-CM is due for an overhaul. "The ability to expand enumeration for a particular procedure category is limited because of the physical numbering constraints contained in the current ICD-9-CM system," said Leon-Chisen. "Consequently, some categories provide vague and imprecise procedure codes."

The AHA has been pleased with field-test results of ICD-10-PCS so far, she explained. "Results indicate that ICD-10-PCS can easily accommodate the expansion of new procedure codes. Coders working with ICD-10-PCS also found the new system to be efficient, logical, and easy to understand and learn."

While coding change is necessary, however, migration to ICD-10 would be costly and complex and should not occur until three years beyond implementation of Health Insurance Portability and Accountability Act regulations, Leon-Chisen said. She also recommended that HCFA work the cost of implementing significant new regulations into the Medicare prospective payment rate updates.

AMA: We do not support ICD-10-PCS

One organization does not think that ICD-10-PCS should be implemented. "Based on the AMA’s support for the elimination of complex regulatory burdens mandated by the Medicare program, the AMA does not support the adoption of ICD-10-PCS," testified Michael Beebe, a project director at the American Medical Association (AMA) in Chicago. The ICD-10-PCS system would replace the Current Procedural Terminology coding system, which the AMA developed in 1966. Beebe made these points against implementation of the coding system:

• Implementation will only add to the regulatory burden faced by physicians and other health care providers.

• The coding system is complex and excessively formal, Beebe said. "PCS is not based on the natural language of physicians and other health care professionals, but rather a highly structured system of character positions with embedded meaning."

• ICD-10-PCS is a substantial departure from ICD-9 and from all existing health care code sets. The system departs from traditional terminology and anatomic organization, Beebe said. This means that an "informed individual cannot begin coding by using an index, intuitive reasoning, or clinical knowledge."

• ICD-10-PCS would require significant resources to implement, both in terms of systems and coder and provider education.

Beebe also expressed concern that the some of the chapters and sections have a limited ability to expand within the system’s seven-character alphanumeric structure and that the process for maintaining and updating PCS has not been defined.

Like the AHA, the AMA has concerns about the cost associated with implementing the new coding system. The cost could include significant training of new staff and computer system changes that will likely be needed to accommodate additional characters, Beebe said. Providers need greater simplicity in the Medicare program, he said. Because of the ICD-10-PCS’ complexity and its inherent problems, the AMA says the system may not be worth the implementation cost.

HCFA also announced at the ICD-9-CM Coordination and Maintenance Committee meeting that it would hold a public meeting on the use of physician query forms. A formal announcement including location, date, and details will be placed in the Federal Register, according to AHIMA sources. The public meeting is expected to take place at the end of this month.