USA Playing Catch Up

31 August 2006 (Last Updated August 31st, 2006 18:30)

While most of the developed world uses the ICD-10 classification system, the USA continues to lag behind. Jori Frahler, director of federal affairs at the Medical Device Manufacturers Association, says using the ageing ICD-9 system leaves the USA vulnerable and isolated on the world stage.

USA Playing Catch Up

The International Classification of Diseases (ICD) was developed by the World Health Organization to promote international comparability in the collection, classification, processing and presentation of morbidity and mortality statistics. ICD codes are the most widely used codes in healthcare.

Currently in its 10th edition, ICD-10 was adopted by the UK in 1995. However, the USA still uses the ninth edition, ICD-9, which was published in 1977. Today, ICD-9 is no longer able to precisely delineate the clinical picture of a patient. It is also running out of codes. As such, the USA's adoption of the 10th edition clinically modified diagnostic coding system (ICD-10- CM) and procedure coding system (ICD-10-PCS) is imperative.

Although the US National Committee on Vital and Health Statistics (NCVHS), the National Centers for Health Statistics and the US Centers for Medicare and Medicaid Services (CMS) developed a transition plan for ICD-10 in 1993, the process is still being debated.

Legislation mandating adoption of ICD-10 has been introduced and is being debated in Washington. For those in the medical technology industry, this debate is welcome because, as modern medicine has progressed and medical technology has become more sophisticated, ICD-9 has become obsolete.

AN OUTDATED SYSTEM

There are many problems, both nationally and internationally, stemming from the fact that the USA is using an older classification system. For example, because most industrial nations and more than 100 countries use ICD-10 to report mortality data, the USA's data are now incompatible with the rest of the global community.

In addition, the USA’s failure to use the international standard for the collection of diagnostic data severely weakens its ability to track and respond to external public health and bioterrorism threats. This could have severe implications in the event of a global avian flu outbreak, for example. In this situation, the USA would not be able to assign proper diagnostic codes to the disease, potentially adding a layer of chaos to not only the domestic healthcare system, but the entire global health community.

Moreover, the terminologies and classifications from the 1970s no longer work with a 21st century healthcare system. That is why the USA needs to adopt ICD-10. Not only will ICD-10 take the current code set from 24,000 codes to 207,000, it will also allow for a more detailed description of procedures.

For example, the sixth digit of the seven-digit ICD-10- PCS code reflects the use of a device that remains in a patient after the completion of the procedure. This level of specificity is needed to allow for precise tracking of device-dependent procedures. Beyond the need for global harmonisation of diagnosis codes, this level of specific coded health data helps with billing, claims processing, pricing and payment.

In 2003, in an effort to encourage the USA to move towards ICD-10, NCVHS reiterated its view that ICD-9 was "increasingly unable to address the needs for accurate data for healthcare billing, quality assurance and health services research", and that it was "in the best interests of the country" to move expeditiously to replace it. With the continued delay in adopting ICD-10, it has become clear that Congress must pass legislation mandating its adoption.

THE LEGAL DEBATE

In October 2005, the House of Representatives Ways and Means Health Subcommittee chairman Nancy Johnson (RCT) introduced HR 4157, the Health Information Technology Promotion Act of 2005.

"Interoperable information networks will require modern classification systems for summarising and reporting health data."

This legislation provides for the adoption of ICD-10 in October 2009. Surprisingly, however, the ICD-10 provision within the broader bill is causing quite a debate on Capitol Hill.

Currently, both the US House Ways and Means Committee and the US House Energy and Commerce Committee have shared jurisdiction over this bill, and each committee hasmarked up its own version of it. But the US House Energy and Commerce legislation does not include a provision calling for the adoption of ICD-10.

Nevertheless, the medical device industry and hospital and coding associations are continuing their efforts to support the passage of legislation adopting ICD-10 by the end of 2006.

It is not just industry that is voicing its concerns about the antiquated coding system. At the 12th Annual Meeting of the Medical Device Manufacturers Association (MDMA) in Washington DC, the CMS administrator, Dr Mark McClellan, described the current coding system during his keynote address as "bursting at the seams".

Other CMS officials have described ICD-9 as 'antique' because the coding system no longer accurately describes the diagnosis and procedures of care delivered in the in-patient hospital setting. Furthermore, with the USA’s push towards adopting national electronic health records, interoperable information networks will require modern classification systems for summarising and reporting health data.

Equally important, ICD-10 will allow hospitals to track patient care processes and allow for accurate reimbursement – potentially eliminating fraud and abuse in the US healthcare system.

Expanding and improving the coding system would also provide CMS with more flexible and accurate nomenclature, especially in identifying the broad range of new medical technologies. It would also reduce the time lag for introducing codes for new procedures into the claims processing system.

WHAT’S TAKING SO LONG?

Opposition to adopting ICD-10 is due to concerns about the cost and administrative burden of implementing more than 200,000 new diagnosis and procedure codes. The cost of upgrading computer systems and retraining coders is also an issue.

However, such arguments only delay the inevitable because all parties agree that the move to ICD-10 must occur at some point. Therefore, the debate is really about when the USA will implement it.

Those opposed to the adoption of ICD-10 in 2009 are pushing for a 2012 implementation date. Yet supporters of ICD-10 believe that six years is too long to wait, especially since this debate has been ongoing since 2000. As US legislators try to move towards a compromise, those stakeholders with a vested interest in seeing ICD- 10 implemented sooner rather than later have put forward recommendations.

Furthermore, a coalition of Washington-based associations (the Medical Device Manufacturers Association, the Advanced Medical Technology Association, the American Health Information Management Association, the Federation of American Hospitals and the American Hospital Association) continues to stress the importance of this issue on Capitol Hill.

Specifically, the coalition is supportive of implementing ICD-10 in 2009 because the expanded code set will provide more accurate and detailed clinical information that can improve quality measurement and patient safety activities while allowing for more accurate reimbursement, which will help identify and reduce fraud.

Whether or not the House of Representatives decides to act now and pass legislation promoting the adoption of ICD-10, one thing is clear: the current system is outdated. Both a multitude of stakeholders and the US Federal Government are negatively affected because the current coding system is not meeting the country's healthcare data needs.