Letter to the Editor: Ever Been Bitten by a Killer Whale?

Dear Editor,

Ever been bitten by a killer whale? Have you sustained burns while waterskiing? Been hit by a spaceship? Know someone who was sucked into a jet engine more than once? Though these sound bizarre, if a new and controversial medical coding system goes into place a year from now, those are exactly the kind of questions doctors across Alabama will soon have to ask patients in order to list a patient’s diagnosis and treatment plan.

When a patient is examined by a doctor, the patient’s diagnosis and treatment plan are “coded” by the doctor. Each diagnosis and prescribed treatment, everything from broken bones and sprained ankles to more serious incidents such as cardiac events and strokes, has a code number. These codes are established by the World Health Organization to classify diseases and other health-related problems.

The present list of codes being used, ICD-9 (International Classification of Diseases, 9th Edition), contains roughly 13,000 codes. While updates are periodically required to keep up with changes in medicine, the switch from ICD-9 to ICD-10 is massive, with nearly 70,000 new and oftentimes bizarre codes that will add little or nothing to the care of patients. Indeed, in most cases, it will require considerably more time than the current system to find the right code, taking away from the time a doctor can spend with his or her patient. Everyone involved in the delivery of health care who submits claims to insurance companies – from doctors to hospitals – will be affected.

In theory, these new codes could allow for better tracking of health threats, like infectious diseases. But, there’s no indication that switching coding systems will really improve the care of patients. Health care should be about the patient, not the paperwork.

The Medical Association of the State of Alabama believes there has not been enough testing of this new system, particularly in rural areas, like so much of Alabama. Do Americans really need a code for “hurt at the opera?”

Bizarre codes aside, this issue is quite serious and the stakes are high. Patients trust their physicians to diagnose and treat them to the best of their ability so the patient’s health can improve. But if physicians can’t find a code or put down the wrong code, insurance companies may delay or even deny necessary treatments.

While better testing by the federal government would ease some of the concerns my colleagues and I have regarding ICD-10, there’s little or no indication that this totally new coding system will improve delivery of health care. I can’t help but wonder whether the switch to ICD-10 might mirror the launch of Healthcare.gov, which technicians are still trying to debug. Patients can’t wait that long for their treatments.

While our medical coding system may need updating, now is not the time as the entire American health care system is still reeling from implementation of the Affordable Care Act. With the 2017 due date of ICD-11 right around the corner, we’ll be doing this all over again in less than three years.

“Head banging into wall, multiple encounters…” wonder if there’s a code for that?

Ronald Franks, M.D.
President,
Medical Association of the State of Alabama

ICD-10: Headache for Doctors; Heartache for Patients

*Below is the letter Medical Association and President Ronald Franks sent to Alabama’s Congressional Delegation urging support to delaying implementation of ICD-10 until October 2017..

Jan. 7, 2015

Dear Alabama Congressional Delegation;

On behalf of the Medical Association of the State of Alabama and our more than 7,000 physician members, we urge you to support delaying implementation of the new medical coding system known as ICD-10 until October 2017.

Forced adoption of this new coding system, which is scheduled for Oct. 1, 2015, will require everyone in a medical practice who touches a patient’s chart – from the physician to the person submitting the claim to the insurance company – to learn four times as many new medical codes as the current system, ICD-9. While the 16,000 medical codes in ICD-9 are well-known, ICD-10 contains more than 68,000 diagnostic codes. There are more than 250 codes for diabetes alone, and with four times as many codes as ICD-9, the government and insurance companies will have four times as many reasons to use ICD-10 coding mistakes to deny medical care!

While spending more time with patients is what patients and physicians want, under ICD-10 we will instead spend more hours in front of a computer screen scanning 68,000 medical codes looking for the right one. Not only will ICD-10 have no direct medical benefit for patients, this mandate is also a tremendous financial burden for medical practices already operating on shoestring budgets. The U.S. is the only country implementing all 68,000 new codes and the only country tying a massive coding system to a complex billing system. Further, experts from the Centers for Medicare & Medicaid Services warn physicians may not get paid for three to six months due to ICD-10’s extensive and complicated implementation. With the likely improbably the system works properly by Oct. 1, 2015, medical practices can’t absorb such long delays in payment.

The transition to ICD-10 is expected to cost more than $1.64 billion over 15 years, with more than 40 percent of that expense coming from the cost of upgrading information technology systems for different participants including the government, insurance companies, physicians and hospitals. While many hospitals are in favor of ICD-10 implementation this year, the people treating patients and responsible for navigating all 68,000 codes – physicians – stand firmly against implementation and in favor of a two-year delay. Physicians will be hardest hit by ICD-10 since the massive cost of software and training is not as easy to spread over a small medical group as it is over an entire insurance company, hospital system or government agency.

Forced adoption of ICD-10 has very real consequences for physicians and the timing could not be worse, when financial strain on medical practices is at its highest point in history. As physicians struggle to implement costly electronic health records and meet stringent quality measures under Medicare’s Physician Quality Reporting System, at the same time we never know when Congress might allow the flawed Medicare SGR formula, or “doc fix,” to expire, further cutting already inadequate Medicare payments by 20 to 30 percent. While our patients want better care and society demands innovation, physicians are drowning under a tsunami of government regulations, and adopting ICD-10 this year will only add to the problem.

Please don’t force this on medical practices this year. Instead, help us by stopping mandates like ICD-10 that stretch our resources and limit the time we spend with our patients. With ICD-11 coming in the near future, we ask your support for a delay of ICD-10 at least another two years so we can change how it will be implemented to protect physicians and patients. We may find that skipping ICD-10 entirely and moving to ICD-11, which is more compatible with electronic medical records, makes more sense. Please tell Speaker Boehner, Chairman Fred Upton and Chairman Pete Sessions that delaying ICD-10 for two years is a priority.

Thank you for your consideration.

Dr. Ronald Franks
President, Medical Association of the State of Alabama

Cc: U.S. Sen. Jeff Sessions
U.S. Sen. Richard Shelby
U.S. Rep. Robert Aderholt
U.S. Rep. Mo Brooks
U.S. Rep. Bradley Byrne
U.S. Rep. Gary Palmer
U.S. Rep. Martha Roby
U.S. Rep. Mike Rogers
U.S. Rep. Terri Sewell

Alabama Physician Lone ICD-10 Dissenter During Congressional Hearing

MONTGOMERY – As the lone voice for physicians in a room filled with insurance company and hospital representatives, Jeff Terry, M.D., a Mobile urologist, urged a Congressional panel not to implement a massive revision to medical coding known as ICD-10, which he believes could force doctors out of business and threaten patients’ access to medical care.

“The vast majority of America’s physicians in private practice are not prepared,” Dr. Terry told the U.S. House Energy and Commerce Health Subcommittee last week. “Physicians are overwhelmed with the tsunami of regulations that have significantly increased the work for our practices. Physicians are retiring early, which could leave countless numbers of patients without a doctor.”

Dr. Terry’s and most physicians’ viewpoint on ICD-10 is at odds with insurance companies and hospital systems, which can more easily absorb the cost of new technology, training and personnel that ICD-10 compliance will require. Small medical practices can’t shoulder the burden of this “costly unfunded mandate” so easily Dr. Terry, a past president of the Medical Association of the State of Alabama, said.

While the current medical coding system ICD-9 has 13,000 codes, ICD-10 contains more than 68,000 codes including more than 250 for diabetes alone. Though other countries have adopted ICD-10 already, the United States is the only one planning to implement all of the 68,000 new codes and link both a massive coding and complex billing system together.

Unless Congress takes action, ICD-10 will be implemented on Oct. 1, 2015, adding to the growing list of government regulations Dr. Terry said makes it more and more difficult to provide the quality care his patients want and deserve.

“It is harder and harder to keep the patient as the primary focus in our daily activities. ICD-10 is viewed as another expensive distraction with little demonstrated value to improving patient care. The huge costs certainly outweigh the very few benefits. Based on data from other countries, doctors will be forced to reduce the numbers of patients they see after ICD-10 is implemented,” Dr. Terry said.

View the press release

Watch Dr. Terry’s testimony.

Flawed Implementation of ICD-10 Less than Six Months Away

*Editor’s Note: The following is a special editorial from Dr. Jeff Terry, past president of the Medical Association, who has closely followed ICD-10 and testified before Congress concerning the need to delay implementation to mitigate the negative effects on medical practices.

Bill in U.S. House Would #StopICD10

Rep. Ted Poe (R-Tex.), supported by six of his Republican colleagues including Rep. Mike Rogers (R.-Ala.) and Rep. Mo Brooks (R.-Ala.), has introduced a bill to block the government-mandated transition from ICD-9 to ICD-10 diagnostic codes set to take effect Oct. 1.

ICD-10 Switch Will Cause Problems in the ER

Researchers found 27 percent of the 1,830 commonly used emergency room ICD-9 codes had convoluted mappings that could create problems with reporting or reimbursement. Further, they found that when they looked at more than 24,000 actual clinical encounters in the ER, 23 percent could be assigned incorrect codes if recommendations of the Center for Medicare and Medicaid Services were followed.

State Lawmakers Urge Congress to Delay ICD-10

MONTGOMERY ─ An Alabama Senate Joint Resolution urging Congress to delay the mandated implementation of ICD-10 on Oct. 1 and lessen the burden on Alabama’s medical practices was enacted this week.

“The Centers for Medicare and Medicaid Services is forcing this unfunded mandate on the health care community, and it couldn’t come at a worse time,” SJR 79 sponsor Sen. Tim Melson, M.D. (R-Florence), said. “Physicians are already overburdened by federal reporting regulations, such as meaning use of electronic health records and the Physician Quality Reporting System that will straddle the ICD-10 start date of Oct. 1. Adding ICD-10 to the mix will only make matters worse for physicians who are only trying to treat their patients.”

If implemented on Oct. 1, the International Classification of Diseases and Related Problems, 10th Version (ICD-10), will replace the current ICD-9 system requiring physicians and their office staff to transition to a coding system with more than 68,000 diagnostic codes – four times more than ICD-9’s current 13,000 codes. Though other countries have adopted ICD-10, the U.S. is the only country planning to fully adopt ICD-10’s complete catalog of 68,000 diagnostic codes and tie it to a medical billing system.

Jeff Terry, M.D., a Mobile urologist and past president of the Medical Association, was the only physician to testify before a Congressional panel earlier this year that the implementation of ICD-10 could force doctors out of business and threaten patients’ access to medical care.

“The vast majority of America’s physicians in private practice are not prepared,” Dr. Terry told the U.S. House Energy and Commerce Health Subcommittee. “Physicians are overwhelmed with the tsunami of regulations that have significantly increased the work for our practices. Physicians are retiring early, which could leave countless numbers of patients without a doctor.”

Physicians widely agree the conversion to the new coding system will not improve patient care, but the overnight conversion to the new system could provide insurers with four times as many reasons to deny necessary medical services and procedures for patients because of coding errors.

“CMS is putting the computer between the doctor and the patient with ICD-10,” Sen. Larry Stutts, M.D., (R-Tuscumbia), co-sponsor of the resolution, said. “As we saw with the rollout of the federal health exchanges, there were a lot of technical problems. With CMS planning to implement ICD-10 on one single day, there are no guarantees we won’t see the same types of problems again. Thirteen thousand codes are already too many. Instead of adding more complicated coding we need to simplify the process.”

Transitioning to ICD-10 requires an abundance of costly and time-consuming education for physicians and staff, software, coder training, and equipment testing. This unfunded mandate will be most costly for private medical practices forced to pay $80,000 to $2.7 million to complete the transition.

Read more about Act 2015-279 and delaying implementation of ICD-10.

Association Supports Rep. Palmer’s ICD-10 “Grace Period” Bill

The Medical Association of the State of Alabama has endorsed H.R. 2652 by Congressman Gary Palmer (R-AL-06), which will protect patients’ access to care and lessen the burden on physicians, particularly in rural and smaller practices.

The “Protecting Patients and Physicians Against Coding Act” would give physicians a two-year grace period in which they would not be penalized for errors with the new federally mandated ICD-10 system that’s used to document code medical procedures and services. ICD-10 contains more than four times the codes used with ICD-9. For physicians, more time spent poring over tens of thousands of medical codes during a patient’s visit equates to less quality time with that patient.

“We are very concerned about the ICD-10 mandate,” George “Buddy” Smith Jr., M.D., president of the Medical Association, said. “Not only does it not improve patient care, but it may provide insurers four times as many reasons to deny necessary medical services and procedures because of coding errors.”

John Meigs, M.D., a family physician from Centerville and a member of the Medical Association’s Board of Censors, said he anticipates serious problems if H.R. 2652 is not adopted.

“The new coding system does nothing for patients or doctors. It’s for insurance companies and bean counters,” said Dr. Meigs. “It will get in the way of the care patients in rural areas badly need. There hasn’t been much in terms of a trial run. To avoid serious disruptions, there’s going to need to be a grace period where physicians get a chance to get used to this new system.”

Congressman Palmer thanked the Medical Association for supporting his bill, the “Protecting Patients and Physicians Against Coding Act.”

“Physicians and other health care providers are in the business to provide care, not to master a complicated and burdensome federally mandated coding system,” Congressman Palmer said. “Protecting patient access to health care is very important. Rural areas and small towns are most at risk from the implementation of ICD-10, practitioners in those areas with smaller practices tend to have fewer resources and they rightly focus on patient care instead of government coding. Because of this, I offered an amendment to recent to legislation delay ICD-10’s implementation. Unfortunately, the amendment was not accepted.”

ICD-10: 75 Days and Counting

UPDATE July 17, 2015: ICD-10: 75 Days and Counting

Medical Association asks all health plans in Alabama to provide a One-Year “grace period”

Only 75 days remain until ICD-10 is scheduled for implementation but a step in the right direction was taken last week by CMS in announcing a 12-month grace period for physician coding errors in Medicare claims. This move by CMS is a direct result of pressure put on the agency from state medical associations nationwide and from members of Congress like Rep. Gary Palmer, who introduced a bill in the U.S. House with a similar grace period.

“While the Medical Association has been an outspoken opponent of ICD-10 and remains so, the inclusion of a grace period makes this federal mandate less problematic for medicine,” Medical Association President Buddy Smith, M.D., said.

Not 48 hours after breaking the news to Alabama doctors about the ICD-10 grace period, Dr. Smith penned a letter to all Alabama health plans and payers asking them to also provide a 12-month “grace period” for coding errors.

“While there are still many details to be worked out, this week’s announcement is a good start, and we will ask private payers and Alabama Medicaid to follow those same transition-period guidelines,” Dr. Smith wrote.

The Medical Association has been one of ICD-10’s most outspoken opponents, taking to the public and media examples of just some of the ridiculously specific codes that make up ICD-10.

Despite the controversy surrounding ICD-10, there has been room to poke a little fun at the hyper-specific coding system that includes some weird and obscure codes for bizarre medical injuries. There’s even an illustrated book, Struck by an Orca: ICD-10 Illustrated.

Additionally, the Association has been on the front lines educating members of Congress about the real-world effects ICD-10 will have on medical practices in Alabama.

“The new coding system does nothing for patients or doctors. It’s for insurance companies and bean counters,” John Meigs, M.D., a family physician from Centerville and a member of the Medical Association’s Board of Censors, said. “It will get in the way of the care patients in rural areas badly need. There hasn’t been much in terms of a trial run. To avoid serious disruptions, there’s going to need to be a grace period where physicians get a chance to get used to this new system.”

But the Association also employed educational and advocacy efforts closer to home with state lawmakers as well, especially in the Association-supported Alabama Senate Joint Resolution by Senators Tim Melson, M.D. and Larry Stutts, M.D.

However, not all physicians see ICD-10 as a problem and claim no outrageous expenses or ill effects on their practices during the transition, according to one news service.

“We did not have special training,” Edward M. Burke, M.D., of the Beyer Medical Group in Missouri, told the House subcommittee in February and reported in HCPRO online. “We did not spend ANY money in preparation. We did not see less patients, and our practice did not suffer. As providers, it was not frustrating or scary. It just was.”

To be clear, the Medical Association still opposes implementation of ICD-10 on Oct. 1, as Dr. Smith said, the grace period is “a good start.” However, we still have much work left to do, including preparing for the implementation in 75 days that no one wants to do. As well, questions remain, particularly regarding the grace period’s coverage of services provided by hospital-based physicians. The Association is asking CMS for guidance in this area and will provide that information to our members as soon as it becomes available.

Additionally, here are some other resources that may help in preparations for ICD-10:

• ICD-10 Quick Start Guide
• CMS’s “Road to 10” (tool to create customized action plans)
• CMS’s main site for ICD-10

The Medical Association will present “Update on ICD-10 and Quality Measures” on Saturday, Aug. 22, at Embassy Suites in Birmingham-Hoover. Register online here.

UPDATE July 8, 2015: Not 48 hours after breaking the news to Alabama doctors about the grace period, Medical Association President Buddy Smith, M.D., penned a letter to all Alabama health plans and payers asking them to also provide a 12-month “grace period” for coding errors.

“While the Medical Association has been an outspoken opponent of ICD-10 and remains so, the inclusion of a grace period makes this federal mandate less problematic for medicine,” Dr. Smith wrote. “… the Medical Association is requesting that all health care payers and health plans in the state of Alabama adhere to and adopt the most recent guidelines from CMS regarding a grace period for physician ICD-10 coding errors …”

Between our work with the Alabama Congressional Delegation to build support for Rep. Gary Palmer’s legislation calling for an ICD-10 grace period to passage of the Alabama Senate Joint Resolution requesting a penalty-free transition for doctors to the request that all Alabama health plans and payers also provide a grace period, the Medical Association has worked tirelessly to mitigate the negative impact that ICD-10 may have on medical practices and patient care.

UPDATE July 6, 2015: Responding to mounting pressure from physicians’ groups and Congress, the Centers for Medicare & Medicaid Services announced it will allow additional flexibility for physicians as they transition to ICD-10 on Oct. 1, beginning with a one-year reprieve from coding error penalties.

“The Medical Association has been on the ICD-10 front lines for a very long time,” George “Buddy” Smith Jr., M.D., president of the Medical Association, said. “While there are still many details to be worked out, today’s announcement is a good start, and we will ask private payers and Alabama Medicaid to follow those same transition-period guidelines.”

Dr. Smith noted the Association has worked with the Alabama Congressional Delegation and state officials on ICD-10 to find any way possible to mitigate the effects of the unfunded mandate on medical practices. In fact, the recent American Medical Association resolution calling for a ‘grace period’ was championed by Alabama physician Dr. Jeff Terry.

Today’s announcement addresses the following areas:

• Claim denials. For the first year, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes. Medicare will not deny payment for these unintentional errors as practices become accustomed to ICD-10 coding. Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This transition period will give physicians and their practice team’s time to get up to speed on the more complicated code set. Medicare Administrative Contractors and Recovery Audit Contractors will be required to follow this policy.
• Quality-reporting penalties. Similar to claim denials, CMS will not subject physicians to penalties for the Physician Quality Reporting System, the value-based payment modifier or meaningful use based on the specificity of diagnosis codes as long as they use a code from the correct ICD-10 family of codes. Penalties will not be applied if CMS experiences difficulties calculating quality scores for these programs as a result of ICD-10 implementation.
• Payment disruptions. If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians.
• Navigating transition problems. CMS has said it will establish a communication center to monitor issues and resolve them as quickly as possible. This will include an “ICD-10 ombudsman” devoted to triaging physician issues.

Free help solutions include “Road to 10” primers aimed at smaller physician practices with clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation, as well as training videos for other helpful tips.

See also ICD-10 Guidance to help you get ready for ICD-10.