Tag Archives: AMA

Has Hell Frozen Over? AMA Seemingly Accepts ICD-10 2015 Date and CMS Makes Some Concessions to Appease Physicians Worries

Given the AMA’s steadfast and relentless attacks on ICD-10, It came as quite a shock when I read this announcement from CMS.  It appears CMS, while holding to the 10/1/15 compliance date, is meeting some of many physician’s fears regarding hiccups that could happen after the go-live date w/a possible increase in pends and denials.

What are your thoughts?  Did this come as a surprise to you?  Do you think we are out of the woods in regards to any last ditch efforts to delay the 10/1/15 date—again?

Closest Thing to Being a Fly on the Wall: AMA Delegation Debates ICD-10 Options as Compliance Date Nears

Earlier this month, the delegates of the American Medical Association (AMA) met to discuss a myriad of topics, one of which was, yes, ICD-10.  Although they ultimately agreed to lobby CMS for a 2 year no payment penalty (essentially a grace period) on using ICD-10, this signals a change in their strategy by no longer calling for a delay in the compliance date of October 1, 2015.

An interesting change in tactic as voiced by the Oklahoma delegation was an outright boycott of ICD-10 by physicians.  This was quickly moved aside as their legal counsel cited legal issues with this including trouble w/the Federal Trade Commission (FTC).

Read more here.

Newsflash: House Approves Bill That Includes Delay to ICD-10 Date. What Does This All Mean?



A resolution in the House of Representatives passed this morning which contains language that delays the compliance date of ICD-10 by one year to 10/1/15.  This primary intention of this legislation was to offer a 1 year extension to the expected Sustainable Growth Rate (SGR) formula change that was set to reduce Medicare provider reimbursement by 24% beginning April 1.  Within this, a Republican Representative Joe Pitts from Pennsylvania inserted a 7 line section that states that HHS cannot effectively enforcement the adoption of the ICD-10 code set prior to 10/1/15.  As you can see, this ICD-10 delay has no direct correlation w/the intent of the original House measure.  (The Senate has a similar measure that has not yet been recorded and does not have a vote scheduled as of date).  It is also unclear why Representative Pitt inserted this particular language into this specific legislation.

Have you all picked your jaw off the ground yet???

What’s noteworthy here is that almost all of the major physician organizations including the American Medical Association is against the bill, especially the Medicare SGR patch.  So far, the physician groups have been silent on the ICD-10 portion of the bill.  They don’t want yet another 1 year delay in the SGR but real and meaningful change to the formula.  They see the delay as yet another stop/gap measure that will keep occurring year after year until the formula is modified in earnest.  Not surprisingly, AHIMA and other HIM groups are not happy with this measure and are actively encouraging their member constituents to contact their legislators and urge them to vote no.  However, as stated previously, this measure did in fact pass the House this morning.  (Read here for more information regarding how the vote was conducted–it broke from normal rules of conduct).

Before we all go into panic mode as to what this means for our current ICD-10 implementations, let’s take a step back and understand the mechanics of how a piece of legislation becomes a law.  This should be able to put some of this into perspective and give us a better focus on what this all might mean to us.  (Cue ‘School House Rock’ music…….)  Bill

Step 1:  A bill (or resolution) is introduced into a chamber of Congress, either the House of Representatives or the Senate.  There’s a whole bunch of stuff that occurs such as committee and subcommittee meetings, negotiations, studies performed, public hearings held, and then scheduling floor action, debate, and then a vote.  (You can see further detailed information regarding the overall legislation process here).  If the legislation is passed w/a majority vote, it gets referred to the other chamber in Congress.  Since this legislation passed, it continues onto step 2.

Step 2:  This approved legislation is sent to the other chamber where it can undergo the same steps as performed in the first chamber—subcommittee meetings, negotiations, studies, and public hearings.  They can then choose to mark this as received, ignored, changed, or approved.  If there are changes, even minor ones, from the original legislation, it must be reviewed by a Conference Committee composed of negotiators from both chambers in order to reach an agreement.  if an agreement cannot be reached, the legislation dies.  If an agreement is reached, it has to go back to both chambers w/the agreed upon modifications (called a Conference Report) and be approved.

Step 3: If the identical bill passes both chambers of Congress,  it is then sent to the President’s desk for signature if he agrees to the bill.  The President may also choose to not sign it for up to 10 days while Congress is in session and it de facto becomes a law; veto it and members of Congress can attempt to override the veto by a 2/3 vote; or let the bill die if he takes no action while Congress is not in session.

I would just caution everyone to take this w/a grain of salt, at least for now.  There are a lot more hurdles that must be overcome before ICD-10 is officially delayed yet again.  This is by no means a done deal.

Part 1: ICD-10 Frequently Asked Questions and Common Misperceptions

I have been working on an ICD-10 implementation with a payer for quite some time now, since 2010.  I have also been working w/ICD-10 from an industry perspective w/WEDI since late 2008, early 2009.  Most of us know that ICD-10 is not just any ordinary implementation.  It is much different and is forcing all sectors within healthcare to cooperate in unprecedented ways than ever before.  Payers (including state and federal government entities)  are clearly motivated to ensure providers are trained and ready to start coding using ICD-10 come October 1, 2014.  For the most part, large provider organizations such as hospitals and large group practices have the money and know-how on what to do to implement ICD-10 and build in the appropriate time frames to get this done.  However, smaller organizations such as solo physician practices and rural and safety net hospitals may not have the savvy or know-how of how to even begin this body of work.

Since 2009, I have been attending different conferences, webinars, and provider outreach calls through CMS and different state agencies.  Below are some of the most commonly asked questions I’ve been hearing about ICD-10 from provider groups:

1) Q: I am a xxxxxx {orthodontic, home health, DME, physical therapist, dental, etc} practice.  Does ICD-10 affect me? A.  If you are currently using ICD-9 diagnosis codes today to file your claims, then yes, you will be impacted by ICD-10.  Dental practices typically only use diagnosis codes when they file a CMS-1500 claim for a procedure that needs to get filed under the patient’s medical benefits such as a type of dental surgery.  The 837D (dental) transaction is new as of 5010 and includes the ICD version indicator (optional) and diagnosis codes (optional) fields on it.  As an FYI, diagnosis codes maybe filed on a dental claim if the member’s dental plan has enhanced benefits, such as additional routine cleaning visits for pregnant women or members with certain chronic diseases such as diabetes.

2) Q: Does the move to ICD-10 impact procedure codes?  A: ICD-10 does impact inpatient procedure codes that are only used to report out at the header level of facility claims.  This is primarily done for the purpose of DRG calculation.  ICD-10 will NOT impact CPT-4/HCPCS codes.  (These are governed by a different entity altogether, the American Medical Association).

3) Q: Is there a crosswalk between ICD-9 and ICD-10 available for me to use to get my practice ready for ICD-10?  A: CMS has made GEMs (General Equivalency Mappings) available for free on the internet.  GEMs is a forwards (ICD-9 to ICD-10) and backwards (ICD-10 to ICD-9) academic exercise, if you will, of all the potential translation possibilities between the 2 different code sets.  However, ICD-10 is vastly different than ICD-9 and does not contain a one to one map for ALL scenarios.  In order to do a true translation from ICD-9 to ICD-10, one must take into consideration the clinical intent of the code or codes being translated.  For instance, a current medical policy on treating pregnant women who have diabetes may not have the equivalent ICD-10 diagnosis codes listed since ICD-9 does not currently have a single diagnosis code to denote maternal diabetic cases.  However, ICD-10 does.

4) Q: Will my vendor (e.g. EMR, clearinghouse, billing service) get me ICD-10 ready?  A: It depends.  An analysis needs to be performed on how ICD-9 codes are selected today—is it by the clinician on a paper superbill; a picklist on the EMR during the clinical encounter; or does a billing service select it based on the clinical record?  A practice needs to take charge of this and not depend on an outside entity or a hardware or software update to fully remediate them for ICD-10.

5) Q: What is CMS or my other payers doing to train me on using ICD-10?  A: This is a question that I think the industry is really struggling with right now.  The general rule has always been that payers cannot tell providers how to code and especially to code for reimbursement since the claim must be coded based upon facts as documented in the medical record.  It is unethical and can be seen as fraudulent for a payer to tell/suggest a provider to use a specific code in order to get paid.  It’s as simple as that.  There are also industry standard guidelines on how a provider is to submit claims.  For instance, a full E&M visit should not be billed more than once every 3 years since this higher level of service (and therefore reimbursement) is not warranted for an annual checkup.  But, payers need to ensure providers are proficient coding in ICD-10 to ensure disruptions to claims processing and payment and other servicing to providers (and ultimately members) do not occur.

To combat this somewhat, most payers are referring providers to publicly available ICD-10 training-related information posted by different professional healthcare and government groups such as the AMA, AAPC, AHIMA, WEDI, and CMS.