March 12, 2013

Physician Education Regarding ICD-10: Sources of Ambivalence and How to Address Them

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As hospitals and health systems prepare for the transition to ICD-10, many gifted and intelligent individuals in the health information management (HIM) field are becoming increasingly frustrated by the apparent ambivalence of physicians toward ICD-10 education. Physicians are generally intelligent and extensively educated individuals. One might anticipate that they would be easily engaged in high-quality ICD-10 education. Yet many physicians remain reserved and somewhat unmotivated to prepare for ICD-10. Let’s consider the causes of this.

Physicians are professionals delivering clinical services to patients. ICD-10 is the global standard for communicating clinical information in modern terminology. Logically, it should be endorsed by those in the field of medicine, yet it is perceived by many to be a regulatory device being imposed on the profession. To this end, there seems to be a significant disconnect between reality and perception. We only need to look as far as the American Medical Association (AMA) to identify one source of such ambivalence. In 2011 AMA President Peter Carmel stated that "the implementation of ICD-10 will create significant burdens on the practice of medicine, with no direct benefit to individual patients' care." Yet ICD-9 is clearly obsolete, and it already has been replaced in every other developed nation in the world. This anti-ICD-10 bias certainly has been picked up by many physicians, however, particularly once the AMA leveraged the Centers for Medicare & Medicaid Services (CMS) to delay implementation from October 2013 to October 2014.

Even recently, the AMA and affiliates in a letter to CMS stated that “stopping the implementation of ICD-10 and calling on appropriate stakeholders to assess an appropriate replacement for ICD-9 will help keep adoption of EHRs and physician participation in delivery and payment reform models on track, and reduce costly burdens on physician practices.”

Why is the AMA so opposed to ICD-10? The answer may lie less with the profession of medicine than it does with the business model of the AMA. The procedural component of ICD-10 (PCS) has much greater specificity than CPT® procedural coding and offers a more logical basis for unified coding of procedures. Is the AMA perhaps concerned about loss of revenue? The current CPT manual retails for $85. According to a recent report, there are about 850,000 physicians in the U.S. Physicians must have a current copy of the CPT manual in their office, and there are multiple supporting publications and royalty income sources derived from CPT intellectual property. The AMA, as a publishing entity, has a financial interest in opposing any potential threat to its revenue. But simply from a practical perspective, how interested would a typical physician be in committing time to learning a new system that the AMA now is requesting not be implemented at all?

How to Address The Sources of Ambivalence

The first and by far the most significant source of ambivalence that needs to be addressed is that which is being created by CMS itself. The final deadline for implementation of ICD-10 initially was set for 2013. Then, based on pressure from the AMA, CMS folded and redefined the term “final” to mean “maybe final, unless we change it again.” It is difficult to criticize physicians, because they’re not the only ones being ambivalent. And again, one underlying source of physician ambivalence is, of course, the AMA itself. At the end of the day, does the AMA advocate for the profession of medicine, or for its own revenue? Many physicians are concerned about this. A recent Jackson & Coker survey suggested that 77 percent of physicians say that the AMA does not represent their views. This could explain current AMA membership being just 15-18 percent of the physician population. It is difficult for any hospital or health system to deal with these fundamental sources of dissent.

However, there are areas where impacts can be made. Discussions with physicians always should begin with patient care. ICD-10 has been adopted by the rest of the developed world because it provides more accurate clinical information, which is essential for epidemiologic study, transitions of care, utilization of the EHR, and many other valid clinical applications. Even in the inpatient setting, physicians recognize the risks of inadequate communication during patient handoffs.

Perhaps the strongest argument, however, is that which is based on medical professionalism. Individual physicians will acknowledge and endorse strong clinical arguments even if they are opposed by the AMA. I have stressed to physicians the value of ICD-10, and they have proven very willing to listen. As we enter into discussions of ACOs, bundled payments, the CMS-HCC system, and other inevitable evolutions of our healthcare system, physicians can be engaged as advocates of documentation improvement, accurate quality metrics, and, fundamentally, better patient care.

Let’s just hope CMS doesn’t fall off the wagon again.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel, and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Paul is vice president of physician services for J.A. Thomas & Associates (a Nuance company). He is also an AHIMA-approved ICD-10-CM/PCS trainer.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Paul Weygandt, MD, JD, MPH, MBA, CPE