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 Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.

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