AMA opposes implementing ICD-10; industry leaders react

The American Medical Association opposes ICD-10 and aims to seek an 'appropriate replacement,' but those who have invested millions in the switch say they won't change their plans.

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In its 65th Interim Meeting in New Orleans, the American Medical Association's House of Delegates voted to vigorously oppose implementing ICD-10 across health care, as mandated by the Centers for Medicare and Medicaid Services (CMS). AMA leadership will now assess just how it will try to stop the new disease coding set, scheduled to replace ICD-9 on Oct. 1, 2013.

Health information management leaders -- charged with leading the ICD-10 training, software implementation, and systems integration already in process at many facilities -- reacted with sympathy to the small, independent medical groups that comprise the AMA's membership. However, they aren't altering their ICD-10 rollouts based on the AMA's opposition to it.

Claims using ICD-10 codes will require more granular documentation than those in ICD-9, making physician participation in ICD-10 conversion key to successful reimbursement. Some facilities have begun training physicians with mock claims or by sitting them down with coders during routine documentation reviews for live claims currently employing ICD-9 codes, to show them what additional information will be required for the same claim due to ICD-10 changes.

Implementing ICD-10 not just a mandate; it'll improve documentation, too

If CMS doesn't extend ICD-10 deadlines, does the AMA resolution point to a growing loathing of ICD-10 among physicians -- and represent what could be a widening rift between physicians and the coders who seek better documentation from them in order to get claims paid?

Text of AMA Resolution 216

  • RESOLVED, That our American Medical Association vigorously work to stop the implementation of ICD-10 and to reduce its unnecessary and significant burdens on the practice of medicine (Directive to Take Action); and be it further
  • RESOLVED, That our AMA do everything possible to let the physicians of America know that our AMA is fighting to repeal the onerous ICD-10 requirements on their behalf. (Directive to Take Action); and be it further
  • RESOLVED, That our American Medical Association work with other national and state medical and informatics associations to assess an appropriate replacement for ICD-9. (Directive to Take Action)

Source: AMA

"It certainly doesn't make their job easier, that's for sure," said Sue Bowman, director of coding policy and compliance for the American Health Information Management Association (AHIMA). "However, from what I've heard from a lot of organizations…they have gotten good involvement from their physicians, so some organizations have been successful that way."

Lori Jayne, HIM director and privacy officer at the Lahey Clinic, said that physicians connected to the health system -- with hospitals and physician offices spread throughout greater Boston and New Hampshire and conducting more than 1 million patient visits annually -- have been proactively implementing ICD-10 and cooperating with her department's efforts to ready Lahey for the switch.

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For the most part, she said, Lahey's physicians see ICD-9 as an obsolete disease classification system. They also buy in to the more robust ICD-10 code set, and the accompanying detailed care documentation, since it will yield more quality indicators to research and, eventually, improve care.

Lahey physicians also get how the movement toward more specific documentation and measurement of the severity of patient illnesses involved with ICD-10 will lead to benchmarks that will give rise to comparative ratings -- and competition -- between physicians. "They have to be the best…and our doctors will be incentivized based on their outcomes measurement," Jayne said. "And it's public. They don't want to be a bad doctor on that list."

There are further justifications for physicians providing more detailed care documentation, said Juliet Santos, senior director of business-centered systems and leader of ICD-10 efforts for the Health Information and Management Systems Society (HIMSS). Better documentation in general helps protect a physician from liability, but it helps them get paid more accurately.

"We shouldn't be doing good documentation because of ICD-10 only or because of ICD-9," Santos said. "They should be doing prudent and thorough documentation to ensure that they have documented what's done and what services have been delivered."

She added that ICD-10 codes will eventually help the health care sector develop the business intelligence and analytics to support new payment models, as well as to mesh U.S. public health data with that of the rest of the world already on ICD-10. While that sharing is going on now, she said, the U.S. can only participate on a limited basis because its health system still is stuck in ICD-9.

AMA floor debate decries cost, complexity of implementing ICD-10

The AMA resolution, passed during the group's semi-annual policy meeting after being introduced by the state associations of Alabama and Mississippi, joined similar moves by the American Association of Clinical Urologists and American Urological Association. After the resolution's introduction, physician leaders from several other states testified that implementing ICD-10 would cause financial and workflow problem for physicians, at a time when physicians are in various stages of EHR implementation.

The ICD-9 to ICD-10 conversion will likely be a greater challenge for smaller hospitals and medical groups than for their larger peers. This has led some health care leaders to sound alarm bells, suggesting that the mandate will drive smaller hospitals either into bankruptcy or to consider consolidation with larger health systems.

"At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel, M.D., said in a press release. "The timing could not be worse."

AHIMA’s Bowman acknowledged that smaller physician offices could be hardest hit by the cost and inconvenience of implementing ICD-10. Jayne concurred, noting that, while larger health systems such as Lahey have the resources to lead ICD-10 initiatives, smaller independent medical groups might have a hard time keeping up with the staff training and financial outlays they can involve.

However, Bowman also pointed out that many of those smaller offices belong to specialists who use a smaller subset of ICD-10 codes than general practitioners. That would make the transition less painful.

The resolution calls for AMA to assist other health care leaders in finding a "replacement" for ICD-10. Santos isn't sure what replacements the group might have in mind. "Put it this way: Nobody's going to reinvent the wheel at this point in time, and we don't have those resources or that kind of bandwidth in this industry," she said.

Jayne agreed. "We're kind of welcoming [ICD-10]. The coding for ICD-9 doesn't really represent the broad spectrum of patient care, and we do have the tools to implement this."

Might CMS delay -- or scuttle -- ICD-10 implementation?

The timing of the AMA resolution is curious. Physicians, along with the rest of the health care world, have been hearing about the transition to ICD-10 for many years. The National Committee on Vital and Health Statistics first suggested a transition to ICD-10 codes back in 1993 -- the same year the World Health Organization published the codes -- and formally recommended ICD-10 implementation a decade later. CMS took action and proposed the change in August 2008. The AMA declined to be interviewed for this story regarding its resolution.

While the AMA rank and file had plenty of time to protest before now, Jayne said it probably took this long for a grassroots protest among the association's members to boil over at their policy meeting and get formalized into the resolution that passed this week.

It's not the first time the group has spoken up, though. Back in 2009, at the behest of the AMA, CMS delayed the ICD-10 implementation timeline from Oct. 1, 2011 to the current date. CMS also pushed back the deadline for adopting HIPAA version 5010 electronic transaction standards, which are necessary to support ICD-10 codes, from April 1, 2010 to Jan. 1, 2012. 

HIMSS’ Santos, like others interviewed by SearchHealthIT.com, said the AMA's latest resolution didn't surprise her, as the association represents the physicians in smaller groups who are most vulnerable to the financial pressures exerted by meaningful use, ICD-10 implementation and other IT mandates.

Like HIMSS, AHIMA is advising its members to stay the course with implementing ICD-10.

In recent years, many of the IT vendor and health care providers who are HIMSS members have invested millions of dollars in preparing for Oct. 1, 2013. Although HIMSS doesn't plan to take a stance for or against the AMA resolution, it's advising members to keep moving "full steam ahead" on implementing ICD-10 unless CMS changes the deadline schedule.

That, she thinks, isn't likely to happen -- although CMS did announce a 90-day grace period for HIPAA version 5010 enforcement. While the Jan. 1, 2012 deadline remains intact, HIPAA covered entities won't be penalized for noncompliance prior to March 31. That announcement followed the Medical Group Management Association's call for CMS to develop HIPAA version 5010 contingency plans so medical groups not yet ready for the new standard could keep their revenue streams open.

Like HIMSS, AHIMA is advising its members -- health information managers in charge of ICD-10 readiness at their organizations -- to stay the course with implementing ICD-10.

Jayne plans to monitor the industry to see what happens next, but won't yet recommend any changes for Lahey's ICD-10 implementation efforts. "The AMA always takes the lead on the protests," Jayne said. "The [American Hospital Association] usually follows behind -- it will be interesting to see what the AHA comes up with."

In 2002, the AHA wrote to the NCVHS in support of a conversion to ICD-10.

Santos encouraged health care stakeholders -- including physicians worried about implementing ICD-10 -- to use HIMSS' ICD-10 Playbook for guidance. That free resource was developed in conjunction with more than 20 other groups, including AHIMA.

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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