ICD-10 Postponement Opens the Door to ICD-11?

With CMS confirming that they are considering a delay in the final mandate for ICD-10 past the October 1, 2013 current deadline,  there are some discussions going on about skipping it entirely in favor of ICD-11.

Some things about ICD-11 – The base version from WHO is expected in May 2015.  After that, the United States will probably need another two years for development of the US version.  The earliest it would be available for study would be 2017, and we would need another 4 years to implement it – so that brings us out to 2021, way too far in the future.

Second and most importantly, we do not favor penalizing the companies that have started work on time on ICD-10.  The health care industry has spent hundreds of $millions already on ICD-10 education, assessments, etc.  Some hospital organizations are not happy about the delay, either.

It would be best for health plans, hospitals, and physicians to use the extra time to implement ICD-10 correctly.  There are consortiums that have sprung up to help with this effort.  We’ll be discussing this more at HIMSS 12 this week in Las Vegas, NV.

Discussion has been that ICD-10 is a steppingstone to ICD-11, so it is probably a good thing to do.  Also, ICD-9 has about had it, so we can’t see keeping it around another 10 years.  Note that ICD-10 procedure codes have nothing to do with the diagnosis codes or ICD-11, so that is a non- factor.  The ICD-10 procedure codes for use in hospitals are a significant improvement.

The theory of a staggered start to ICD-10 has also been floated – that CMS might continue to mandate the October 1, 2013 date for some plans or providers while offering relief to others.  One theory is that smaller entities or rural providers might get relief.   This seems equitable – that those who have invested in ICD-10 and can afford to meet the ICD-10 date would continue on their current path, while those who cannot afford it get a break.  However if one considers the national impact of a staggered start, it means that payors would have more dual processing of ICD-9 and ICD-10 claims to consider, based on a new factor – size of the provider and perhaps their location.  Would this relief really help or cause more havoc?  We’ll all learn more when CMS clarifies their statement that “certain entities” might be impacted.

There are clear benefits in our mind of ICD-11, including SNOMED CT clinical vocabulary supporting Electronic Medical Records.  However, the ICD-10 train has left the station.  It should be arriving – just later than scheduled.

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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