Why did the AMA vote to try to skip ICD-10 and move to ICD-11?

And Will This Succeed?

The industry has known that ICD-10 has been planned for 15 years. It is not surprising that AMA announced its intent on Tuesday June 20th 2012 to research ICD-11 on the eve of the largest health insurance (health plan) conference of the year – AHIP.  AMA’s anti-ICD-10 stance has been presumed to be an anti-health plan tactic.  However, it isn’t just health plans that would be hurt by skipping the ICD-10 mandate.

Also, remember that AMA may try to influence, but it does not make the final decision on whether ICD-10 will be used vs. ICD-11.  This of course excludes rumors that the White House asked Secretary Sebelius at HHS to delay ICD-10.  Perhaps a Senator from Oklahoma who was a physician had something to do with it?  I wonder. Sen. Coburn is a retired Republican.   I believe it has more to do with the AMA trying to continue to ensure its control over physician compensation with CPT codes. ICD-10 begins to chip away at CPT codes for ambulatory procedures, which determines how physicians get paid outside the hospital setting.  Never mind that AMA has set a precedent that specialists get paid more than generalists, leading to an acute shortage of primary care physicians.  According to the New York times, “This fee schedule contains about 7,000 distinct nonsurgical and physician services, classified under a nomenclature based on the Current Procedural Terminology to which the American Medical Association holds jealously guarded intellectual property rights.”

AMA is becoming less relevant as many physicians decide that they can’t afford to be in independent practice and now work for hospitals.  This is unfortunate, but if you look at the fact that AMA itself has biased payments via its RUC  Committee / lobby with CMS, it has created a self-fulfilling prophecy that new medical school graduates with large debt to repay for medical school choose a higher paying specialty area instead of becoming a primary care physician. Primary care doctors are the first line of defense in our health system, and they can help with the continuity of care for their patients, determining when a specialists are needed.  Delaying ICD-10, AMA believes, will help preserve its relevance, and its control over physician compensation. Sadly it seems that AMA hasn’t served its own members well, or the healthcare industry.

ICD-11 won’t “arrive” in a year or two. Our health system needs to digest it and then determine when and how to move to it.  While ICD-11 has some intriguing benefits, it is a long way off. 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, skipping to ICD-11 is effectively 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.  While some health plans are ahead relative to hospitals, some hospital organizations and other providers are not happy about the delay, either.

Let’s look at HIPAA 5010 as an example.  CMS mandated this new standard to go into effect by January 1st, 2012.  I of know a modestly funded clinic in Minnesota that dutifully complied with HIPAA 5010 for submitting their claims starting on January 1st. But because CMS announced a “discretionary enforcement period,” sending a message to the industry that HIPAA 5010 was delayed, the small clinic was penalized – twice.  They spent precious working capital modernizing their electronic data interchange (EDI) systems, then when they started to submit claims in HIPAA 5010 that health plans could not process, their payments were delayed.  “No good deed goes unpunished,” as the old saying goes. The clinic employs physicians, coders, administrative staff and others who ran the risk of not receiving their payroll checks.

Why don’t we look at ICD-10 as a way to create jobs?   There are many people who could be re-trained to be coders, and IT staff from other depressed industries could be re-purposed to help with healthcare and ICD-10.

Related Posts

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


ICD-10 – Let’s Get On with IT


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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