Please note: Friday, August 24, 2012
The Department of Health and Human Services (HHS) today announced the final rule that makes the proposed one-year delay-from Oct. 1, 2013, to Oct. 1, 2014-final for the implementation of ICD-10.  

It seemed not so long ago we in the healthcare industry had the date ingrained into our brains -October 1, 2013 was THE day.  No delays, no exceptions!  We've been living and planning for this implementation date since it was first announced in January 2009.  For the better part of three years, many organizations have done significant amounts of preparatory work and invested many dollars to ensure their facility and its employees are steadily readying themselves for the transition from ICD-9-CM to ICD-10-CM/PCS.  

But, in February 2012, all gears came to a screeching halt when the acting CMS administrator Marilyn Tavenner agreed to reconsider the final implementation date.  This decision snowballed and created uncertainty, frustration, and concern over whether this new system will be put in place or not and when that date will be.  In response to the complaints by the American Medical Association (AMA), it was officially announced in April 2012 by the Department of Health and Human Services (HHS) that they would like to propose that the implementation date be delayed one year to October 1, 2014. 

This proposed delay caused an eruption of opposing debates and laundry lists of why we should not delay the implementation date.  There were two big and respected voices that had opposing views for their own individual reasons, the American Health Information Management Association (AHIMA) and the American Medical Association (AMA.)  

The current coding system
AHIMA - ICD-9-CM is antiquated and broken
The ICD system was intended as a classification system that should be updated every 10 years.  To date, ICD-9-CM has surpassed its third decade of use (originally implemented in 1979).  Continuing to limp along with ICD-9-CM for any length of time jeopardizes the ultimate goal of cost savings by limiting the option of implementing more precise code descriptions rather than relying on unspecified or ambiguous code descriptions commonly seen in ICD-9-CM. 
An additional problem that exists is the limitation of space with ICD-9-CM.  Currently, when codes are considered for addition, the question of "Where do I place this code?" is often raised because it cannot be logically sequenced in the chapter in which it belongs. Lastly, the maintenance of using ICD-9-CM for a longer period of time means taking up precious time for the Coordination and Maintenance committees to discuss revisions, additions to both ICD-9-CM and ICD-10-CM/PCS. 

AMA -ICD-9-CM still works
The existing codes in ICD-9-CM should be sufficient and adding an exorbitant amount of new codes "does not increase the quality of care received by their patients." 

It is understandable that physicians may not see the direct impact on quality of care, but rather the additional burdens that ICD-10 would create. Many of the quality initiatives which will have a positive financial impact on physicians require more specific data and are somewhat dependent on ICD-10 implementation, such as meaningful use, EHRs, and value-based purchasing.  Physician services generally utilize a limited range of diagnosis codes since many are within a certain specialty group, so targeting the sheer number of codes isn't really a valid issue to cite as a reason for not implementing on schedule. 

Hospitals (specifically acute inpatient admissions) will bear the heaviest of burdens but yet there is still adamant support for staying on schedule by the American Hospital Association (AHA) and AHIMA for the implementation to ICD-10.  Inpatient admissions must be coded with both ICD-10-CM and ICD-10-PCS.  ICD-10-PCS is a fundamentally different procedure coding system in basic structure and in application and will increase the costs significantly to upgrade hospital billing systems for both diagnosis and procedure code sets.  ICD-10-CM is very similar in structure and application as ICD-9-CM.  Many of the coding guidelines are identical.   Coders and other coding related professions (such as CDI programs) will necessitate a much broader base of code set education to learn a vastly different coding system so they may secretly be happy about the proposed delay.  At least physicians will still be using CPT and HCPCS II codes after ICD-10 implementation.  Physicians do assign diagnosis codes from the same code set as inpatient hospitals but payments for physician services are more closely tied to the HCPCS codes (CPT and HCPCS II).

Diagnosis codes are used to support medical necessity so it would be better to have more specific codes so that physicians can easily and clearly support medical necessity (which is a common payer denial reason) if they had a more robust code set to use.  ICD-10-CM may not solve all these issues but increased support for medical necessity is one of the many benefits anticipated. 

The addition of so many new codes is seen as "clutter" that yields no increase in quality of care. Yet many of the additional specificities that increase the number of codes are somewhat straightforward and logical additions that are currently seen in CPT procedure code modifiers, such as identification of laterality (right, left, bilateral).  The identification of side affected is common in documentation for physicians so it should not cause undue burden or add to what is currently documented.   Additional categories of ICD-10-CM diagnoses with a vast number of codes increasing the total number of optional codes are for external causes which may or may not be required by some payers.  One exception may be for worker's compensation programs that require detailed information regarding causes and other mechanisms that result in injury or development of other health care conditions stemming from a workplace environment to clearly show liability.  When focusing on quality, physicians will have the ability to track via coded data the quality of different treatment methods and should be a direct benefit to their patients. 

Other concerns, although not as publicly mentioned, may surround the CPT manual itself and the far reaching financial implications if this coding system were to be replaced.  Currently, physicians report for their services using CPT codes (owned, copyrighted and governed by the AMA) and will continue to do so after ICD-10 implementation.  This was a point of concern for the AMA based off a 2003 letter urging the National Center for Health Statistics (NCHS) and HHS to only use ICD-10-PCS for acute inpatient facility procedures after implementation.   This raises questions of whether the motivation for this concern is about quality for the procedures reported for their patients or is it possibly a fear of losing their direct tie to the CPT codes since they hold the copyright.    

In looking at ICD-10-PCS, this system could likely replace CPT in the long term, streamlining the coding process by only having one diagnosis and one procedure code system.  Services would be paid based off the place of service or other defining factors.  The evaluation and management services (E/M) chapter would likely be of concern to convert to ICD-10-PCS tables; however, one must remember that the majority of the guidelines that govern the correct application and assignment of these codes are not published in the CPT manual itself but rather are in a set of guidelines titled the CMS Documentation Guidelines (1995 and 1997 versions). 

Implementation Dates
AHIMA - No more than a one-year delay
Although AHIMA really prefers to not delay at all from the October 1, 2013 deadline, they insist that it should not be longer than one year (October 1, 2014).  They realize at this juncture that a delay is inevitable considering the lost time by some organizations who may have put on hold or at least slowed down their pace for implementation planning efforts due to the uncertainty of when this new system-and some may ask IF this new system-will be finalized and implemented.  Considering that the announcement from January 2009 has taken three-plus years to evoke a true opposition from a major entity (like the AMA), it yielded such obvious frustration with the government that they even considered putting the brakes on at this juncture.  AHIMA states that if there is a one-year delay, that the decision will be final and will not be extended to those who fail to comply.  To me, the date should be gilded in stone and not in clay that can be modified at a later date if so desired. 

AMA - 2014? 2015? Or later?
The AMA breathed a sigh of relief with the official proposed delay of ICD-10 to October 1, 2014.  Lately, there has been some speculation of whether the AMA plans on future pushback even for this extended date and press for a longer extension to possibly 2015 or later.  Clearly the government felt that their concerns were valid; however, in some literature, there has also been discussion about waiting for ICD-11 as a viable option.  ICD-11 is in the beta testing phase and is anticipated for release in 2015-2016 but its implementation (if awaited) in the U.S. would likely not occur until after 2020. With this type of very lengthy delay, there would be no argument (unless a new one arises in the meantime) for being able to implement on schedule. 
However, a delay such as this would be catastrophic for the U.S.  The ICD-10 code set is designed to allow for the eventual changeover to ICD-11.  If the U.S. were to decide to wait on this system, we'll be going through this exact situation less than ten years from now.  It does not solve the issues in the interim.

There is also a growing concern that some entities will procrastinate and not use the additional time wisely.  The U.S has known about the eventual implementation to ICD-10 for approximately 15 years.  Realizing of course that it wasn't officially announced until three-plus years ago, this delay has given rise to healthcare facilities, physician practices, billing agencies, educational institutions, and other related companies who work with or service these types of organizations to reevaluate their timelines and implementation efforts.  We also are faced with the fear that the government may be swayed again by large healthcare sectors as we near October 1, 2014. A one-year delay may be exactly what is needed to give some breathing room but not enough to thwart efforts already begun.  I think adjustments on timetables will be minimal and will be seen as mostly positive but a delay of more than a year may really defeat the purpose of attempting to implement many of the government quality initiatives that were set in motion.  Hopefully we'll have guidance very soon about what the next steps will be in this ongoing venture towards ICD-10.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, is the Director of HIM and Coding for HCPro, Inc. She is the lead instructor of the Certifi ed Coder Boot Camp® and serves as the manager of the Certifi ed Coder Boot Camp® programs. She is an AHIMA-certifi ed ICD-10 trainer and developed the HCPro ICD-10 Basics Boot Camp®. She is also the lead instructor and developer of the Certifi ed Coder Boot Camp® Online, the Certifi ed Coder Boot Camp® Online -Inpatient Version and the Evaluation & Management Boot Camp - Professional Services Version.