AMA Pushes for More Delay, But ICD-10 is Necessary

Thomas Selva, MD, is chief medical information officer at the University of Missouri Healthcare. Last week we spoke about the last-minute attempt by the American Medical Association to once again halt ICD-10 adoption through Congressional legislation, and about how University of Missouri Health is using new technology to meet the challenge of ICD-10.

HealthLeaders: We’ve seen this movie before. What do you think?

Selva: AMA is a political voice for the physicians. They’re responding to their constituency and their constituency is saying, We’re not ready. Big institutions like ours can bring tremendous amounts of resources to bear, and we’re still concerned.

HealthLeaders: You almost make the AMA’s case when you say this.

Selva: Yes and no. We’ve got to do this [ICD-10]. The reality is, we don’t have enough specificity in our code. Look at orthopedics, they’re crying for more specificity in their codes. There’s no room left in ICD-9, and in all honesty, we are very late to the party. Certainly Cerner and Epic both are leveraging [technology from] Intelligent Medical Objects to make it as fast as possible, but at the end of the day, it’s still more clicks, and in a busy clinic day, that’s a 30-, 40-minute stretch that you’re adding to the end of your day by doing all that extra work.

HealthLeaders: CMS says ICD-10 doesn’t affect ambulatory, or at least not nearly as much as it does affect hospitals and inpatient.

Selva: On the hospital side, where there’s a lot of dollars attached to each patient for each encounter, and way more work, that’s true. On the outpatient side, you have lower dollars for each encounter, but you see a lot more patients in a day. We admit and discharge 27,000 patients a year, but we admit and discharge from our clinics 600,000 patients a year, so you could argue that the clinics don’t make as much money per patient, but boy oh boy do they do a lot of work.

HealthLeaders: CMS says reimbursement for outpatient and physician office procedures will not be determined by ICD-10 codes, as outpatient and physician office claims are not paid based on ICD-10 diagnosis codes but on CPT and HCPCS, which are not changing.

Selva: It’s going to depend on the payers [and] how much pushback they’re going to give. Remember, the documentation load on the inpatient side is incredibly high, because it’s not just you the treating physician. It’s who consulted, who did daily progress notes. If you’re the surgeon, it’s the follow-up notes. You’ve got the global fees. So yeah, I would argue that on the outpatient side, not as much. But if you’re taught to be specific on the inpatient side, that’s going to bleed over into the outpatient side. It’s not as much as a payment mechanism. I’m looking more at what physician behavior is going to change.

HealthLeaders: I hear CEO-level executives saying we need ICD-10 to do better diagnoses. When I’ve written about ICD-10, I’ve found that it really has been mostly about the billing, and there are other things that are done to deal with diagnoses. There’s CPT. There’s SNOMED, which is part of meaningful use. I wonder about how it looks to have a CEO stand up there and say, We need ICD-10 to do better diagnosis. I think a lot of people would take issue with that.

Selva: Certainly ICD-10 is more specific than ICD-9. The more specifically you can code something, the better you can go back and look at what you’ve done. If you’re trying to do evidence-based medicine, if you’re trying to use protocols, if you’re trying to use your electronic medical record to give you clinical decision support, that is all leveraged off a diagnosis. You mention SNOMED. Before meaningful use, physicians didn’t know what you were talking about. SNOMED is ICD-10 on a wicked set of steroids. And it’s been around forever. It’s well-intentioned. I’m assuming that’s why the feds chose SNOMED to code problems for meaningful use, but I have got to tell you, that’s a different coding scheme, so again, it’s created a great market for Intelligent Medical Objects to come up with the Rosetta Stone to somehow convert the two.

HealthLeaders: You’re using Cerner, which is creating ICD-9 codes today still for you. Are you actually creating some ICD-10 codes with Cerner?

Selva: We’re testing partners with Cerner, so we get new code like every Friday. I’m not sure this is generally available to all their clients, but we’re using something called Physician Transition Early, a product they have that, as you’re searching for a diagnosis code today for someone in the office, it’s showing you the ICD-9 code and the closest match to an ICD-10 code. It’s not asking you to specify yet. However, let’s say you need to have labs every three months for the next year. If I draw up that order, one of those lab orders that’s in that recurring scheme is going to cross that October 1 threshold, and so immediately we get a pop-up saying, You need to specify that diagnosis, and it gives you what we call a physician diagnosis assistant, which is very fast. It’s an incredibly quick filter. In less than five clicks, you can get to the specific code that you need, and you’re done. And you’re going to find all the larger EMR manufacturers are doing this. They’re coming up with ways to try to simplify it as much as they can.

HealthLeaders: You’re also doing problem lists in SNOMED already.

Selva: Yes. There was no choice there. We had to do that to meet stage 2 of meaningful use. That was a requirement of the federal government. … We have a 15-year history with Cerner, so our problem lists are pretty large, so we had go through on the back end and run an automated script that would do a best match, and then if it couldn’t do a one-to-one match, they have a product that allows you to literally sift through the problem list and it will suggest the kinds of SNOMED codes that are close, but you as a clinician need to make that call.

We allowed free texting back in the old days. Everybody had to go through this cleanup. We had to clean up about 450,000 problems in our problem list. But then moving forward, what [Intelligent Medical Objects] does, which is very cool, is that if you are putting in a diagnosis for today, you can just type in natural language in the search field, and it will give you your diagnosis for today. If you want that to be a problem, we can literally drag the diagnosis from today down to the problem list, and it will convert that to SNOMED, and if it can’t, it will pop up a window saying, From the following list, can you pick the one that is the closest match for today’s problem? So it’s about as close to automatic as I think you can get it.

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