Opposition to ICD10 – A Perspective of Self Interest

Last week I read several articles about the current efforts to delay the implementation of ICD10 by the AMA and some of our congressmen, possibly influenced by this organization.  Their extremely weak arguments against implementation focus on their own lack of preparedness for the implementation.  Anyone with any knowledge of what has already been done to prepare for this new code set would realize that the negative impact of another delay would far outweigh any benefits of allowing these procrastinators additional time to prepare.

ICD10 Coding
Opposition to ICD10

As I was reading one of these article last Friday, I was reminded of a similar situation long ago in the late 1980s.  Computers were very new to the healthcare industry.  There was no internet or even electronic claims.  Claims processing procedures were still centered on the typewriter.  Not only did different health plans have different forms, but they had different forms for different types of service.  Medicare and Medicaid had completely different inpatient and outpatient forms.  Each with their own code sets and form locators for entry of these codes.  I worked as a programmer for a hospital information system company in 1984.  We had to develop software that would print data on these forms correctly.  In addition to the claims processing logic that was specific to geographic regions of the country and health plans, we had to deal with the inconsistency of dot matrix printers and the inability to update systems except through the direct application of software from diskettes.  At the time, about 50% – 70% of all software development was dedicated to bill printing programs.  A simple error on where an “X” printed on a form might delay millions in payments.  At most institutions, claims processing was a combination of computer printed forms with team of billers armed with typewriters and a bottle of “white out”.

Then came the development of the UB92 for institutional claims.  It would require a standard form and code sets for all health plans.  It promised to streamline this daunting task of standardized billing software saving billions in the industry and dramatically improving revenue cycle management.  It was a simple concept and on the surface it was difficult to imagine how anyone who participated in claims processes sing would object to this approach.

I was selected to participate in the development of this form and the associated code sets by the Missouri Hospital Association.  The AMA built a national committee and for a couple years, we built this new form to accommodate all the needs of all health plans to collect the data needed to adjudicate claims.  As the implementation date for this form approached, the resistance began.  For ICD10, the resistance seems to come mostly from provider organizations that are unprepared for the new code set or failed to take the deadline seriously.  For the UB92, it was health plans, especially the Medicaid programs, who wanted to continue to get their customized proprietary data, even though it meant that their claims had to be processed manually by providers.  The UB92 form was implemented anyway and became mandatory for all health plans, but the standardization of code sets did not.  Although we could now develop programs for a single form, the software still had to be customized by health plan and the software billing problems were just as widespread as before.

At the request of the MHA, I held a meeting in Jefferson City, Missouri that was attended by the member hospitals and representatives from the state Medicaid program to demonstrate the problem.  At that time, not only did Missouri Medicaid have unique codes for most coded values on the form, but they insisted that all surgical procedures be identified by HCPCS codes instead of the ICD9 codes used by everyone else, including all other Medicaid programs.

Together with some of my customers, we demonstrated the Missouri Medicaid billing procedure.  Since software vendors with a national customer base were unwilling to create software for coding surgeries with HCPCS, each facility would begin with a printed claim designed for Medicare that included the ICD9 codes for surgical procedures.  In addition, there were four other national standard codes that were not used by Missouri Medicaid.

After the claims were printed, they were sent to a billing team which made a photocopy of the claim and used white out on the nine form locators with the data that was invalid for Missouri Medicaid.  They then manually reassigned the values for these codes using code books and cross reference “cheat sheets” and wrote them on the photocopy.  They then loaded the forms in a typewriter and typed the new values in.  This process took between 30 minutes to an hour for every claim.  Then, as now, Medicaid was a significant part of the healthcare business so this represented a significant cost to the industry that had to be absorbed by every Missouri provider to accommodate the unwillingness of a single organization to accommodate a new standard.

As we demonstrated the process, many additional comments came forth from the providers of their own horror stories related to this process.  The Medicaid staff remained silent.  At the end, it was obvious to anyone who attended that the overall benefit of standardization for the healthcare providers of Missouri far outweighed any costs or impact to the this single health plan.  Yet, after the meeting, they continued to refuse to modify their system in any way.  In a letter to the MHA, they stated that their need to use their proprietary codes to properly manage their services, outweighed the needs of the providers.

About ten years later, when electronic claims became commonplace, Missouri Medicaid and most of the other Medicaid’s adopted new standardized systems from commercial vendors like EDS that transformed them from the worst health plans to deal with to some of the best.  However, until that time, they continued to fight change for no other reason than their own self-interest at the expense of billions to Missouri hospitals.

Now, with ICD10 approaching, a small minority threatens to delay the implementation of this code set even though providers, vendors and health plans have spent significant resources preparing for ICD10 and are proceeding with their implementation plans, training and testing.

The arguments of the procrastinators ignore the negative impact of a delay and the disruption it would cause and instead focus on their own unwillingness to prepare for this change and their own self-interest above the benefits this will provide the industry.

I guess my point is that we need to stay on track and remain focused on making sure that ICD10 remains on schedule.  We should not underestimate the ability of a minority to undermine advancement, even if it flies in the face of logic.

AHIMA is continuing to promote a letter writing campaign to congress to stay on the schedule.  They should be applauded for this effort.  If any of you get the opportunity, explain to your representatives in government that we have moved forward to far to turn around and there is not enough time, even if these arguments had merit.


By Kalon Mitchell, President – MEDTranDirect