The case for leapfrogging ICD-10 and holding out for ICD-11 just got a lot more curious. And though it's not here yet, when ICD-11 is ready, it will be something ICD-10 cannot: A 21st Century classification system.
Now that HHS Secretary Kathleen Sebelius has thrown her department's hat in the ring, saying late Wednesday that HHS intends to delay ICD-10, the most pertinent question is how long will HHS push back compliance?
"My opinion is that CMS won't be able to announce three months or six months of delay for ICD-10," says Mike Arrigo, CEO of consultancy No World Borders (pictured above). "They will need to announce a delay from October 1, 2013 to at least October 1, 2014 because of CMS fiscal planning calendars."
Others in the industry are suggesting that even one year is not enough to lighten the burden on physicians,providers and payers enough to make the transition smoother.
"I have a gut feeling they'll go for two years, who knows?" speculates Steve Sisko, an analyst and technology consultant focused on payers and ICD-10. "Maybe January 2015?"
No more mixed signals
There it is on the Department of Health and Human Services Web site, a crystal-clear headline atop a brief explanatory statement: HHS Secretary Kathleen Sebelius announces intent to delay ICD-10 compliance deadline.
"We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead," Sebelius said in the statement. "We are committing to work through the rulemaking process, with the provider community, to reexamine the pace at which HHS and the nation implement these important improvements to our healthcare system."
Whereas acting CMS administrator Marilynn Tavenner was perhaps politically vague when speaking at an AMA meeting on Tuesday by saying that CMS would reexamine the timing of ICD-10 compliance, Sebelius' statement was careful to erase any doubt about HSS's plans.
"HHS will announce a new compliance date in forthcoming rulemaking," the statement explains.
Neither Tavenner nor Sebelius clearly outlined "the rulemaking process" to which each referred. But any kind of rulemaking by the federal government tends to take a while, and there's no reason to suggest that this instance will differ.
A formal process could take as long as a year, while the informal, conducted through the Federal Register, typically calls for a 180-day response period, after which the comments are taken into consideration to shape a new proposed rule. That, in turn, must be evaluated, eating up more clicks of the clock.
"The fact that [Tavenner] mentioned going through a 'rule making process' implies to us that this will take a long time," Wendy Whittington, MD, CMO of Anthelio Healthcare Solutions told Government Health IT in an interview. "A short delay would be much more tolerable than a long one."
If HHS has a tack for fast-tracking the rulemaking process for ICD-10, thus far it has not explained that. But if the agency intends only to change the compliance deadline then perhaps there is a way to abridge that cycle.
A time to question the value of ICD-10 Prior to HHS statement, the AMA praised and AHIMA panned Tavenner's commitment to reexamine the timing.
In an increasingly heated industry-association Civil War, both groups have fired shots, with the AMA calling on Sebelius and House Speaker John Boehner to block ICD-10 entirely, and AHIMA urging the industry to continue apace toward the new code sets.
Any delay, according to Dan Rode, AHIMA vice president of advocacy and policy, would increase costs while diminishing the value of ICD-10 and other health IT projects, including, of course, meaningful use.
HHS acknowledged the need for ICD-10. "ICD-10 codes are important to many positive improvements in our healthcare system," says Sebelius.
Anthelio's Whittington agreed, adding that "pushing the deadline back one year means that we can't complete all aspects of healthcare reform. Information the government needs to collect to provide effective research on what works and what doesn't is tied to the more specific information gathered by the ICD-10 codes. Folks who haven't read ICD-10 don't understand the benefits of the more detailed coding."
Not everyone buys that the U.S. even needs ICD-10 codes, though. The argument against: Cost in education, systems remediation, time and training won't yield better data for analysis and outcomes because resource-crunched U.S. providers will take a band-aid approach, employing crosswalks, GEMs, step-up/step-down approaches rather than moving to ICD-10 exclusively. And the unfunded mandate promises little in the way of ROI to those who implement the new code sets.
Getting to a pure ICD-10 environment could take years. And while proponents maintain that the U.S. needs to catch up to other developed countries that adopted ICD-10 years ago, therein hides ICD-10's great flaw: Other countries adopted it decades ago – it's old and showing its age.
Furthermore, much of the rest of the world doesn't even use ICD-10 for reimbursement in the inpatient and acute-care setting, as No World Borders' Arrigo explains. As a one-payment system Canada, for instance, only uses ICD-10 codes for hospital services, so their total number of codes is smaller than the U.S., adds Deb Grider, senior manager of revenue cycle at consultancy Blue and Co (pictured at right).
"We have multi-payment systems," Grider says. "We code for professional services, we code for radiology services, all different kinds of healthcare services that providers deliver."
An even starker reality is that while ICD-9 was essentially completed in the early 1970's it was created in accordance with theories of health and technology from the 1960's and, likewise, the WHO finished ICD-10 in 1990 so it represents mid-1980's thinking.
"We're moving up 20 years, which is an improvement, but we're still not in 21st Century thinking as far as an underpinning of ICD-10," says Chris Chute, MD, DrPH, who spearheads the Mayo Clinic's bioinformatics division and chairs the WHO's ICD-11 Revision Steering Group.
What's more, Chute participated in what he considers "a fairly objective comparison of the functionality of ICD-10 versus ICD-9. And we're not getting a lot for our money. I don't know how to say it more directly than that," he explains. "The functional improvements in terms of representing patient data in a comparable and consistent way is not dramatically increased in ICD-10; in fact it's almost negligibly increased."
That, despite the fact that the original cost estimates for converting to ICD-10 were off by an order of magnitude, Chute adds, and not in a manner favorable to those physicians, providers, and payers upon who's back the burden of ICD-10 strains like many mythological enduring Atlas's.
ICD-11: What is it?
If a bullet-proof technical reason that the U.S. could not simply leapfrog ICD-10 and adopt ICD-11 in it's stead actually exists, then more than two years of asking just about everyone has yet to uncover it.
Political reasons are bountiful and powerful, to be certain. Spanning the gamut from potential lawsuits by providers who have spent millions already on the conversion being that it is, after all, a law to those who argue that charting a new course now would be more costly, more chaotic than seeing ICD-10 through – even though there is an existing argument that the conversion will be for naught. Add to that list that enormous undertaking of clinically modifying ICD-10 for the U.S.
"To change at this point, given that we are a year and a few months away from the magical transition date, would be, I submit, vastly more disruptive than just staying the course at this point," Chute explains, hastening to add that he is not a proponent of ICD-10, but that "ICD-11 is not ready for prime time."
Not yet, but 2015 is where the forthcoming new ICD-10 compliance deadline and ICD-11 might just intersect.
Should the U.S. delay the ICD-10 compliance deadline just one year, until 2014, then the WHO will have a beta of ICD-11 ready. And if Sisko's gut is correct, and the new ICD-10 deadline flows into 2015, well, then a final version of ICD-11 will be fast-approaching.
When it arrives, currently slated for 2015 (but Chute said it could be 2016), the underlying structure of ICD-11 will be profoundly different than any anterior ICD.
"ICD-11 will be significantly more sophisticated, both from a computer science perspective and from a medical content and description perspective," Chute explains. "Each rubric in ICD-11 will have a fairly rich information space and metadata around it. It will have an English language definition, it will have logical linkages with attributes to SNOMED, it will have applicable genomic information and underpinnings linked to HUGO, human genome standard representations."
ICD-10, as a point of contrast, provides a title, a string, a number, inclusion terms and an index. No definitions. No linkages because it was created before the Internet, let alone the semantic web. No rich information space.
Has anyone even considered ICD-11?
Perhaps the most problematic reality the nascent ICD-11 faces today is that because the U.S. government mandated ICD-10 before anything was known about ICD-11, it ostensibly appears that the people thinking about ICD-11 are limited to the WHO's ICD-11 Revision Steering Committee.
As Blue and Co.'s Grider tells it, most of her hospital clients are trying to kickstart the ICD-10 implementation and not even looking ahead to subsequent coding changes.
And who can blame them? Even the AMA, in all its vehement opposition to ICD-10, would not touch the subject of ICD-11 when asked. "AMA policy does not address ICD-11," a spokesperson says. "The AMA would not be in a position to comment on ICD-11 until we work with others on a required assessment."
The AMA, just like all payers, providers, vendors, everyone else in healthcare today, has more than ICD-10 to contend with.
"I guess my question is: Has HHS looked at ICD-11?" Grider wonders. "I am just guessing but I would say no. With healthcare reform, meaningful use and now ICD-10 everybody is spread very thin. And I can see that when I go into the hospitals, into the medical practices to help them with the ICD-10 transition and see their condition. Everybody is trying to continue business as usual while doing this and that's been a real challenge. And I know the government is spread thin with all the regulations and everything they're trying to do, so I wonder if they're even thinking about it."
Perhaps all are but no one has publicly championed ICD-11 as an ICD-10 alternative. Not even Chute of the WHO ICD-11 Revision Steering Committee. But this week's announcement that ICD-10 will be pushed back again holds at least a nugget of potential that the horizon is broadening to include two ICD options, if not simultaneously, than certainly in rapid succession.
Now that the industry has more time for ICD-10, perhaps it would be wisely-used considering the more modern, more useful ICD-11, either instead of ICD-10 or at the very least to plan two steps ahead.
Because that old saying about the dictionary – that its essentially obsolete by the time it gets printed – just might apply to ICD-10 as well.