Officials at the Centers for Medicare and Medicaid Services plan to replace the ICD-9-CM diagnosis and procedure code set with a significantly expanded set of codes—the ICD-10—by Oct. 1, 2011.
But physician groups are calling the agency's plan rushed and unworkable and want the agency to reconsider its compliance date.
In addition to the requirements for using the ICD-10 code sets, CMS is proposing to require entities covered under The Health Insurance Portability and Accountability Act of 1996 to implement updated versions of electronic transmission standards—the Accredited Standards Committee X12 Version 5010 and the National Council for Prescription Drug Programs Version D.0. Both electronic standards have a compliance date of April 1, 2010. The X12 Version 5010 must be in place before the ICD-10 codes can be used, according to CMS.
The two proposed regulations were published in the Federal Register on Aug. 22. CMS will accept comments on the proposals until Oct. 21.
The switch to ICD-10 has been under consideration by the Department of Health and Human Services since 1997. Size and specificity are two of the biggest drawbacks of the ICD-9-CM code set, according to CMS. Because many of the ICD-9-CM chapters are full, CMS has begun to assign codes to unrelated chapters, so that, for example, cardiac procedures have been put in the eye chapter.
The ICD-9-CM also fails to provide adequate clinical details, according to CMS. For example, the ICD-9-CM has a single procedure code that describes endovascular repair or occlusion of the head and neck vessels. But the code leaves out details such as a description of the artery or vein on which the repair was performed, the precise nature of the repair, or whether it was a percutaneous procedure or was transluminal with a catheter.
“Because of the new and changing medical advancements during the past 20-plus years, the functionality of the ICD-9-CM code set has been exhausted,” CMS officials wrote in the proposed regulation. “This code set is no longer able to respond to additional classification specificity, newly identified disease entities, and other advances.”
CMS also is urging a switch to the ICD-10 code sets in an effort to keep in step with other countries. As of October 2002, 99 countries had adopted ICD-10 or a clinical modification for coding and reporting morbidity data. And CMS contends that because it continues to use ICD-9-CM it has problems identifying emerging recent global health threats such as anthrax, Severe Acute Respiratory Syndrome (SARS), and monkeypox.
Under the proposal, physicians, hospitals, health plans, and other covered health care entities would be required to use the ICD-10-CM for reporting diagnoses and the ICD-10-PCS for reporting procedures. The ICD-10 code sets offer significantly more codes, about 155,000 across the two sets, compared with about 17,000 for diagnosis and procedure codes within the ICD-9-CM.
Beyond size, the ICD-10 code sets also provide greater specificity, such as being able to reflect the side of the body related to the diagnosis or procedure. The more detailed information available with the ICD-10 codes will aid in the implementation of electronic health records and transmission of data for biosurveillance or pay-for-performance programs, according to CMS.
But physician groups say CMS is asking physicians and other health care providers to do too much too fast.
The American Medical Association balked at the idea of implementation of both the updated X12 Version 5010 electronic transaction standard and the ICD-10 coding system in just 3 years. The X12 Version 5010 standard should first be pilot tested before physicians and others are asked to implement it, AMA said.
“This is a massive administrative undertaking for physicians and must be implemented in a time frame that allows for physician education, software vendor updates, coder training, and testing with payers—steps that cannot be rushed and are needed for a smooth transition,” Dr. Joseph Heyman, AMA board chair, said in a statement.
The Medical Group Management Association also objected. While MGMA supports the switch to the ICD-10 code sets, they said that 3 years is not enough time for the industry to implement the new system. Instead of a simultaneous implementation of the X12 Version 5010 standard and the ICD-10 code sets, MGMA is asking CMS to wait at least 3 years after the switch to X12 Version 5010 before implementing the ICD-10.
The switch to ICD-10 needs to be done separately because it will require significant changes from medical groups, according to MGMA. Recent MGMA research indicates that most medical practices will have to purchase software upgrades for their practice management systems or buy all new software in order to implement the transition to ICD-10.