OJAI, CALIF.--Is ICD-10 really that bad? That was one of the issues debated during a session on clinical documentation during the Association of Medical Directors of Information Systems Physician-Computer Connection Symposium.
Harris Stutman, MD, executive director of clinical informatics at MemorialCare Health System in Orange County, Calif., came out in support of the embattled classification standard, first tackling examples of ultra-specific coding that opponents of ICD-10 have latched onto as part of the argument against it.
Critics of ICD-10 who refer to these “strawmen,” such as codes representing “drowning and submersion due to falling or jumping from burning waterskis,” or “struck by alligator” are falsifying their arguments, Stutman said, since these codes are assembled and aren’t primary codes, and will be used so rarely that they will be irrelevant clinically and when it comes to billing.
As far as the experience of countries like Canada in converting to ICD-10 is concerned, while there were staff productivity losses due to the fact that coders are looking for more information in the patient record, there have also been a number of benefits noted by our neighbor to the north, Stutman said.
For example, the data provided in converting to ICD-10 increased the level of specificity for clinical, care costing and decision support reporting and provided more relevant data for epidemiological uses, research and other uses of data for population health management. It also allowed for more opportunities to compare clinical data to advance service delivery and system efficiencies and effectiveness.
Stutman argued that while there will certainly be changes going from ICD-9 to ICD-10, many will be “relatively minor” in relation to the focus of the changes. For example, relatively few specialties will be significantly impacted, he said, pointing out that specialties like cardiology and gastroenterology will likely see a slight increase in the number of codes—“a relatively minor change that should not be expected to increase workload of confusion.”
“The benefits exceed the costs of moving ahead with ICD-10," he added, pointing out that from a reimbursement perspective there is the potential for greater accuracy in matching diagnoses and procedures, as well as the likelihood there will be fewer requests for more documentation.
It should also improve disease management capabilities, he said, “which may be important in managing care effectiveness and quality in an integrated model we have been talking about, and which will be especially important when those data are collected in multiple EHRs and merged through a patient portal into HIEs, data warehouses and other modalities for analytical purposes.”
“There is a reasonable case to be made that we need to go forward,” Stutman said, “And ICD-10 is on the table and most of us have already done the legwork.”
In counterpoint to Stutman’s argument in support of ICD-10, Jonathan Handler, MD, argued that the problem with ICD-10 “from my standpoint, is that it steals time from patients."
For one thing, Handler said, ICD-10 is "ridiculously complex" and requires much in the way of wasteful work duplication.
Regarding the question of coding and laterality, Handler observed, “I’m sorry—how many times is laterality documented in the record already?” He pointed out that laterality may not be specified in the chief complaint, “but it surely is in the nursing notes, and absolutely is documented twice in the H &P,” as well as in the CPOE, RIS, PACS and radiology report.
“And after all that work that we’ve already piled on to document the laterality, I can’t get paid for it unless I re-summarize that entire medical record into a mini-ICD-10 code," he said.
Handler also argued that the expense involved in transitioning to ICD-10 has been greatly underestimated, with costs to practices running three to four times more than anticipated. With the costs involved, as well the time expended on ICD-10, Handler suggested there are better ways to spend healthcare collars and use physician time.
Handler also discussed ICD-11 and SNOMED-CT, but concluded that in the end the choice of terminology is not the biggest problem faced by providers. “The biggest problem is code specificity,” he said. “You can make any coding system impossible, expensive, time-wasting, confusing and complex merely by saying you have to code something to the nth degree of specificity. We don’t want that level of specificity.”