ICD-10: Decision Daze

Don't expect to see a dozen white satellite dishes atop network news trucks or protesters camped outside the entrance of the New Executive Office Building in Washington, D.C.  the administrative home of the Office of Management and Budget (OMB)  awaiting word on the ICD-10 final rule.

Though emblematic of the polarization that has seeped into and stained the fabric of American political discourse of late, the decision of whether the United States adopts ICD-10 and establishes compliance by 2014 nonetheless is not likely to garner the kind of attention generated on that bright sunny day in early June when the U.S. Supreme Court handed down its 5 -4 decision declaring that the Patient Protection and Affordable Care Act was constitutional. 

With little or no advanced warning, publication of the Centers for Medicare & Medicaid Services' ICD-10 final rule will appear in the densely written Federal Register, described in 8-point Times New Roman font.

Devoid of editorial embellishment, straightforward declarative sentences will spell out a new era in healthcare regardless of the implementation date - 2013, 2014, or beyond.

But even the matter of when the OMB releases the final rule (after its vetting among various governmental agencies) has given rise to conjecture. After all, it is a political year, and opinions about ICD-10 have become polarized.

Since the role of the OMB is to "serve the President of the United States in implementing his vision across the Executive Branch," according to the OMB's mission statement, will the OMB publish the final rule before or after the election?

Is it in the best interests of the White House, politically speaking, for the OMB to wait until after the election, when the presidential outcome is known, or for it to release the final rule for publication before election day and risk the possibility of harming the campaign? Some political observers believe that the White House wants no distractions, yet on the other hand, some believe that ICD-10 is too far below the radar screen to be noticed during election season.

By law, the OMB has 90 days to complete its review  or, as the OMB states on its website, 90 days for "review of all significant federal regulations by executive agencies, to reflect presidential priorities and to ensure that economic and other impacts are assessed as part of regulatory decision-making, along with review and assessment of information collection requests."

The 90-day deadline for OMB to complete its review of the final rule comes around the week of Nov. 5. Tuesday, Nov. 6 is Election Day.

And healthcare reform, regardless of the Supreme Court's June decision, is a topic as hot as the sweltering weather both campaigns are enduring as they caravan across battleground states leading up to the election.

Already there's conjecture among those who watch these events as to when OMB will release the final rule for publication. Some speculate that if the final rule is published before the election, you can expect a longer delay for implementing ICD-10. If you read the final rule in the Federal Register after the election, you might discover that CMS stuck to its original timeline of 2014.

But the mystery deepens.

Remember, the proposed rule CMS put forth last spring called for the compliance date to be Oct. 1, 2014. And after posting its proposed rule, there was the mandated comment period during which CMS, we were told, reviewed approximately 500 comments relative to extending the implementation date from 2013 to 2014.

Did CMS, after reviewing and analyzing more comments, elect to extend the compliance date another year, from 2013 to 2015?

As it has countless times before, did CMS blink yet again? Was the agency persuaded by professional associations and societies to move the compliance date one more time?

Consistently opposing the 2014 implementation date and even suggesting a possible indefinite postponement of the international code set in use by 99 other countries has been the American Medical Association (AMA), the Medical Group Management Association (MGMA), and a handful of U.S. lawmakers, notably U.S. Sen. Tom Coburn, MD (R-Oklahoma). Some are calling for congressional hearings on the effectiveness of ICD-10.

However, should CMS simply leapfrog from ICD-10 to ICD-11, as others have suggested?

In a July 19 press release, AMA President-elect Ardis Dee Hoven, M.D. is quoted as saying, "ICD-10 coding will create unnecessary and significant financial and administrative burdens for physicians. It is critical to evaluate alternatives to ICD-9 that will make for a less cumbersome transition for physicians and allow physicians to focus on their primary priority-patient care."

On the other hand, there has been some staunch support of the final rule calling for the 2014 compliance date. Among those stalwart supporters are the American Health Information Management Association (AHIMA) and the College of Healthcare Information Management Executives (CHIME).

Dan Rode, vice president of policy and government relations for AHIMA, pointed out that the ICD-10 structure must be in place before the industry moves to ICD-11. For example, he notes, there are five characters in ICD-9 codes and seven characters in ICD-10 codes  the latter being the same number of characters needed for ICD-11.

In addition to this matter and other technical changes required to set up the transition, Rode said that "we need the kind of data that [ICD-10] will provide to [allow us to] engage in the other programs desired by Congress and others, such as quality initiatives and value-based purchasing."

"CMS made a fairly clear case for why they believe a one-year delay makes sense," said Jeff Smith, CHIME's assistant director of advocacy. "CHIME believes it makes sense and so, hopefully, they [CMS] will not be deterred in their thinking."

Even among most provider organizations, the prevailing sentiment appears to favor keeping to the proposed date of 2014. During one of the weekly "Talk-Ten-Tuesday" Internet broadcasts I co-host with Kim Charland, vice president of consulting services for Panacea Healthcare Solutions, we asked audience members if they thought the U.S. should leapfrog from ICD-10 to ICD-11 (a position advocated by the AMA).

Not surprisingly, 72 percent of respondents said the country needed to implement ICD-10 first, whereas 12 percent voiced concern and said they didn't have enough time to implement ICD-10.

And so it goes.

Did CMS rewrite its proposed rule that would set an Oct. 1, 2014 deadline for ICD-10 implementation? Or did the agency, contemplating the stated positions of the AMA and the MGMA, reconsider and instead send to the OMB a final rule calling for 2015 as the new compliance date?

In the words of Yogi Berra, "It's tough to make predictions, especially about the future."


Chuck Buck is the publisher of ICD10monitor and the producer and co-host of Talk-Ten-Tuesday, a live weekly Internet radio broadcast starting at 10 a.m. ET every Tuesday.