November 5, 2003 – Letter to the Secretary – ICD-10 Recommendations – Attachment II – National Committee on Vital and Health Statistics

Attachment II

National Committee on Vital and Health Statistics

Hearings on ICD-10-CM and ICD-10-PCS Timeline

Introduction

The National Committee on Vital and Health Statistics (NCVHS) has a long and active history in patient classification systems. Classification systems play an important role in nearly all uses of health data, including outcomes research, reimbursement, program evaluation and policy decision-making.

This timeline details the highlights and major milestones of proceedings of the NCVHS and its subcommittees, especially the Subcommittee on Standards and Security. These proceedings specifically relate to the continued discussions to move forward with implementation of the clinical modification of ICD-10 (ICD-10-CM) to be used for morbidity diagnosis classification in the United States and the ICD-10 Procedure Coding System (ICD-10-PCS) to be used for inpatient procedure classification.

In addition, the timeline includes items occurring outside the realm of NCVHS (external reports, letters and other external meetings or actions) related to the possible implementation these two classifications.

Testimony obtained during the April 1997 hearings on the initial candidates for adoption of medical code sets under HIPAA acknowledged the need to move to newer versions of the ICD-9-CM at a later time, but recommended that the initial HIPAA code sets be those that were currently in use.

The NCVHS continued to receive updates from CMS and NCHS on further developments and activities related to ICD-10-CM and ICD-10-PCS. NCVHA resumed hearings on the possible migration to ICD-10-CM and ICD-10-PCS from ICD-9-CM with the April 9, 2002 and May 29, 2002 hearings on ICD-10-PCs and ICD-10-CM, respectively.

1990

The Subcommittee on Medical Classification Systems of NCVHS reviewed chapter proposals from the WHO and preliminary international implementation plans for the 10^th revision of the International Classification of Diseases.

The NCVHS noted that while ICD-9-CM has been responsive to the changing technologies and identifying new diseases that impact heavily on the community, there is concern that the ICD classification system may be stressed to a point where the quality of the system may soon be compromised (NCVHS 1990 Annual Report, page 17).

The November 1990 Report of the National Committee on Vital and Health Statistics Concerning Issues Relating to the Coding and Classification Systems concluded the following:

The Subcommittee review found structural problems with both CPT-4 and Volume 3 of ICD-9-CM.
An ongoing study and evaluation of the feasibility of a uniform procedures code is necessary. Such an evaluation should address HCFA’s responsibility as a catalyst in determining the efficacy of a single procedure code.

1993

The Subcommittee continued to address issues related to the International Classification of Diseases, 10^th revision, focusing on the status and implementation of ICD-10 in the United States, with particular regard to morbidity applications. The Subcommittee initiated a letter from the NCVHS to the Assistant Secretary for Health and Administrator of the Health Care Financing Administration (HCFA) recommending that the Department dedicate resources to determine the feasibility of implementing ICD-10 for morbidity application in the United States.

During 1993, the Subcommittee held three meetings and three working sessions dedicating a substantial portion of the meetings to developing and reviewing its report to recommend that steps be taken to create a single procedure classification system for multiple purposes in the United States.

The NCVHS issued a report on desirability of a single procedure coding system containing the following conclusions:

The single procedure classification system should possess utility as a statistical classification and an administrative tool. Characteristics of such a system are defined.
General resistance to altering existing systems except where changes are considered necessary to reflect current medical trends
Current systems are badly in need of overhaul and consolidation
Pressures for change derive not only from end users who must contend with deficiencies of current systems, but also from political forces that must address major health care reform. The Committee notes that data sets currently do not permit the ability to track patients through the system as they enter and leave various care settings over the course of an illness or over a long period of time.
The Committee realizes that recognition of the necessity for the development and implementation of a single procedure classification system is only the first step in a difficult and time-consuming process. Public and private sector resources will be required to achieve a successful and timely solution to the issues addressed in the report.

Commonly cited flaws of ICD-9-CM and CPT-4 procedure classification systems were also included in the report:

Both Classifications

Lack of space for expansion

Overlapping and duplicative codes

Inconsistent and non-current use of terminology

Lack of codes for preventive services

ICD-9-CM (Volume 3)

Insufficient specificity and detail

Insufficient structure to capture new technology

CPT-4

Non-hierarchical structure

Physician service orientation (not multidisciplinary)

Poorly defined, non-discrete coding categories, with variable detail

1994

May 1994

DHHS OIG issued report on Coding of Physician Services that describes vulnerabilities in the maintenance, use, and management of the CPT-4, as they relate to Medicare reimbursement. The report identified several flaws in CPT-4 codes, guidelines, and index that can lead to improper coding. The report also noted that the guidelines on hospital outpatient services appear to be a particular problem. In November 1988, HCFA informed the CPT Editorial Panel of its concerns in applying

CPT-4 to outpatient services. In a December 1992 position statement, AHIMA stated, “attempts to effectively use this (CPT-4) coding system for the hospital setting have resulted in the inconsistent application of the CPT conventions and the general guidelines.” The report also contains several recommendations for HCFA and the AMA that would correct the deficiencies noted. Prior to publication, HCFA and AMA reviewed the draft report and their respective comments are included.

1995

As noted in the Proceedings of the 45^th Anniversary Symposium of the NCVHS, NCVHS in 1983 and again in 1986 has called for “strong efforts” to develop a single procedure coding system for the United States to replace the use of Volume 3 of ICD-9-CM in hospitals and the American Medical Association’s CPT-4 in ambulatory settings [NCVHS Annual Report 1983-85; Annual Report, 1993).

May 1995

The Subcommittee convened hearings whose primary purpose was to discuss data needs of managed care organizations, using the proposed criteria for a unified procedure classification. Four different models of managed care participated in the discussion (network, group and staff, IPA, and mixed models). There appeared to be consensus for a unified system, given the varied needs of managed care organizations.

The consistent message in written and oral testimony before the Subcommittee was that existing coding systems were not meeting their needs.

1997

April 15-16, 1997

The Subcommittee convened hearings on initial candidates for adoption of medical code sets under HIPAA. Thirty-one organizations provided testimony. Testimony obtained during the April 1997 hearings acknowledged the need to move to newer versions of the ICD-9-CM at a later time, but recommended that the initial HIPAA code sets be those currently in use.

1998

Comments received in response to the NPRM for Standards for Electronic Transactions published May 7, 1998 supported the need to replace ICD-9-CM with ICD-10-CM and ICD-10-PCS. The United States implemented the tenth revision of ICD (ICD-10) for coding mortality data in 1999, and ICD-10 or clinical modifications of it are already in use for morbidity reporting in most other G7 countries.

1999

The Institute of Medicine (IOM) Committee on Injury Prevention and Control recommended that a high priority be directed at ensuring uniform and reliable coding of both the external cause and the nature of injury using the ICD on all health systems data, particularly on hospital and emergency department discharge records. The Committee noted that special efforts should be directed at training to ensure optimal use of the tenth revision of the ICD.

2001

May 17, 2001

During the ICD-9-CM Coordination and Maintenance Committee discussions were held on whether ICD-10-PCS should be named as a replacement for Volume 3 of ICD-9-CM held at the ICD-9-CM Coordination and Maintenance Committee, eleven organizations (American Hospital Association, American Health Information Management Association, American Medical Association, Federation of American Hospitals, American Speech-Language Hearing Association, AdvaMed, Ingenix Syndicated Content Group, Princeton Reimbursement Group, Medical Technology Partners, DRG Review, INC, McKesson HBOC), requested the opportunity to present comments on whether ICD-10-PCS should replace ICD-9-CM, Volume 3. It was noted that timing and resources were of concern to presenters. Of the eleven, only one organization, the American Medical Association did not support going forward with the process that would lead toward the replacement of Volume 3 with ICD-10-PCS

September 2001

In the Benefits Improvement and Protections Act of 2000 (BIPA), Congress addressed requirements for incorporation of new medical services and technologies into the Medicare inpatient prospective payment system. Some of the requirements addressed the lack of detail and shortage of available codes in the current coding system. In the September 7, 2001 Federal Register, CMS noted the limitation of ICD-9-CM regarding the ability to expeditiously incorporate new medical services and technologies into the classification. A number of approaches and techniques used for procedures (such as lasers, minimally invasive techniques and the use of scopes) cannot be readily captured by the current structure of Volume 3. Short-term solutions undertaken by CMS to address limitations of ICD-9-CM, Volume 3 included opening a series of codes that can be used for new procedures and technologies; new procedures would be assigned the next available code. This series of 200 codes provides some additional expansion, however, it should be noted that this approach captures a diverse group of procedures potentially affecting all body systems. The approach is inconsistent with the structure of ICD-9-CM.

2002

April 9, 2002

Subcommittee convened hearings on ICD-10-PCS. CMS provided an overview and a need for ICD-10-PCS to the Subcommittee on Standards and Security. The Subcommittee heard testimony from six organizations (AHA, AdvaMED, Blue Cross Blue Shield Association, AMA, AHIMA and FAH). Blue Cross Blue Shield Association states that NCVHS should thoroughly evaluate the impact of migration to ICD-10 on all aspects of the industry by assembling a multi-disciplinary team to provide input.

May 29, 2002

Subcommittee convened hearing on ICD-10-CM. Several organizations provided testimony to the NCVHS regarding migration to ICD-10-CM: American Academy of Neurology [AAN], American Academy of Obstetricians and Gynecologists [ACOG], American Psychiatric Association [APA], McKesson Information Systems, AHA, AHIMA, Federation of American Hospital (FAH), Johns Hopkins Bloomberg School of Public Health – Center for Injury Research and Policy, and NACHRI, NCHS, American Academy of Procedural Coders, McKesson Corp. With the exception of Blue Cross Blue Shield Association, testifiers supported migration to ICD-10-CM from ICD-9-CM. Blue Cross Blue Shield Association submitted written testimony urging the Subcommittee to wait until the industry has successfully implemented the initial HIPAA standards and that NCVHS thoroughly evaluate the impact of migration to ICD-10 on all aspects of the industry by assembling a multi-disciplinary team to provide input before making a recommendation to the Secretary.

A second panel, comprised of IT representatives from three vendors and 2 health care systems provided testimony regarding system issues related to transitions to new code sets. Several of the presenters have had experience in migration to ICD-10 in other countries. View was that migration was a challenge but could be accomplished as long as there was sufficient lead time (2-3 years) to make systems changes.

August 9, 2002

A GAO report issued to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives, HIPAA Standards: Dual Code Sets Are Acceptable for Reporting Medical Procedures”. The GAO stated in the concluding observations, “Considering the adequacy of ICD-9-CM, Volume 3, and CPT in meeting all of the criteria recommended for HIPAA standard code sets, the practical challenges of implementing a single procedure code set, and lack of empirical evidence to either support or disprove the merits of doing so, we believe that dual code sets for reporting medical procedures are acceptable under HIPAA. In addition, we concur with those representatives of the health care industry who contend that more study is needed to examine the possible benefits of adopting a single code set for medical procedures before its implementation could be considered.”

August 26, 2002

Health Insurance Association of America (HIAA) sends letter to Dr. Simon Cohn (Chair, Subcommittee on Standards and Security). Letter urges NCVHS to take into account all effects and entities involved before making a decision on migration toward and the timeframe for implementation of ICD-10-CM or ICD-10-PCS. Recommendations: conduct thorough impact study with participation from industry groups; allow sufficient time for comments on any decision and proposed rule; and allow sufficient time for industry to implement ICD-10 if that decision is made.

August 27, 2002

AHA sends letter to Secretary Thompson. Letter summarizes the AHA position that ICD-9-CM has outlived its usefulness and supports replacing with ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures; ICD-10-PCS testing shows it is a vast improvement over ICD-9-CM; and that both ICD-10-CM and ICD-10-PCS should be implemented at the same time. Lastly, the AHA does not support adoption of a single procedure classification system for all services. Rather, as suggested by the GAO, the AHA supports a dual approach to procedure coding with ICD-10-PCS for hospital inpatient services and CPT for hospital outpatient and physicians services.

August 29, 2002

Blue Cross Blue Shield of South Carolina, HIAA, and Aetna/American Association of Health Plans provided written and oral testimony to the Subcommittee on the possible replacement of ICD-9-CM with ICD-10-CM and ICD-10-PCS. The recommendation from those presenting is: wait until initial HIPAA mandates successfully implemented; conduct thorough impact analysis including cost/benefit of migrating and not migrating is completed; assess alternatives.

September 23, 2002

AMA sends letter to Secretary Thompson. Letter summarizes the AMA position that it is “unnecessary and potentially detrimental to replace ICD-9-CM, Volume 3 which has served its purpose well and contains only 4,000 codes, with ICD-10-PCS which contains nearly 200,000 codes and is unproven in any setting.” They also cite lack of involvement of organized medicine and the leadership of allied health professionals in the development and maintenance of ICD-10-PCS. Lastly, they urge the Department to consider adoption of CPT as a viable workable alternative to ICD-10-PCS. This letter was co-signed by the American Academy of Family Physicians (AAFP), American College of Physicians – American Society of Internal Medicine (ACP), and American College of Surgeons (ACS).

September 24. 2002

A letter signed by BCBSA, American Association of Health Plans, Health Insurance Association of America, the American Public Human Services Association/National Association of State Medicaid Directors, and the Joint Commission on Accreditation of Healthcare Organizations sent to Dr. John R. Lumpkin regarding transition to ICD-10-CM and ICD-10-PCS. The letter urged that a detailed analysis on the impact of the replacement of ICD-9-CM on the entire health care industry be conducted prior to the NCVHS making a recommendation to the Secretary for Health and Human Services.

October 22, 2002

The Subcommittee on Standards and Security met to discuss ICD-10-CM and ICD-10-PCS. Instructions were given to staff to evaluate the possibility of developing a contract for a cost benefit analysis for new coding systems. They were also instructed on the preparation of briefing materials for the full committee. CMS staff offered to have Rich Averill, 3M HIS make a presentation on ICD-10-PCS to the full committee. Subcommittee members rejected this idea. Staff worked with Dr. Simon Cohn on a briefing package.

November 19, 2002

NCVHS met to discuss the replacement of ICD-9-CM with ICD-10-CM and ICD-10-PCS. The Subcommittee on Standards and Security agreed to contract for a cost-benefit study to inform its recommendations. NCVHS referred to the Subcommittee on Standards and Security the task of defining the scope of the study to be conducted

November 19, 2002

A letter, signed by American Hospital Association, Federation of American Hospitals and Advanced Medical Technology Association sent to Dr. John Lumpkin supporting replacement of ICD-9-CM with ICD-10-CM for diagnosis codes and ICD-10-PCS for all hospital inpatient services. The correspondence urges the NCVHS to send letter to Secretary Thompson, recommending that a proposed rule implementing ICD-10-CM and ICD-10-PCS be issued as soon as possible.

December 10, 2002

The Subcommittee on Standards and Security discusses the scope of work for initiating a contract for a cost benefit analysis of changing to ICD-10-CM/ICD-10-PCS coding systems prior to making any recommendation to the Secretary.

2003

January 2003

A contract is awarded to RAND’s Science and Technology Policy Institute to conduct an impact analysis of moving to ICD-10-CM /ICD-10-PCS. The analysis is to include assessing the full range of implications on current users including costs and benefits (quantifiable and non-quantifiable):

Identify costs, including opportunity costs, associated with transition, including information system changes, rate negotiation, reimbursement methodologies, training, forms changes
Timing of transition, including impact of timing options on costs & benefits, potential return on investment

May 2003

RAND presented study plan and preliminary results at May and August 2003 meetings of the Subcommittee on Standards and Security, respectively.

July 23, 2003

American Health Information Management Association (AHIMA) sends letter to Secretary Thompson urging the Department to take quick and decisive action to adopt ICD-10-CM and ICD-10-PCS to replace the obsolete ICD-9. Among the risks of further delay is placing the US out of step with all other developed countries that have already adopted ICD-10. The letter urges the Secretary to promulgate an NPRM to adopt ICD-10-CM and ICD-10-PCS and offers to work with the Department to make this important change happen soon.

July 31, 2003

American Health Information Management Association (AHIMA) sends letter to Tom Scully, CMS, supporting the adoption of the ICD-10-CM and ICD-10-PCS coding systems and urging them to make CMS’s and the industry’s case known, about this, at the upcoming September NCVHS meeting.

August 6, 2003

American Health Information Management Association (AHIMA) writes to Tom Grissom and Tom Gustafson at CMS urging them to “make their case known” in the upcoming September NCVHS meeting.

August 20, 2003

The Medical Group Management Association (MGMA) sends a letter to Simon Cohn expressing concerns over the potential adoption of ICD-10-CM and ICD-10-PCS. Their concerns included: significant modification to business processes, increased time spent documenting a patient encounter, potential loss of research and benchmarking data, training difficulties, significant increase in costs and delayed reimbursement. They stress the importance of great deliberation, coordinated national strategy and allocation of resources.

August 20, 2003

RAND provided a status report to the Subcommittee on the NCVHS-funded study to determine the impact of migrating to ICD-10-CM and ICD-10-PCS. Preliminary results of impact analysis were also presented.

American Health Information Management Association (AHIMA) and the American Hospital Association (AHA) presented preliminary results of their joint pilot test of ICD-10-CM. The study included more than 6100 records from a broad cross section of health care community that were dual coded by 180+ participants. These initial results indicate that: there is general support for adoption of ICD-10-CM; ICD-10-CM is seen as an improvement over ICD-9-CM; and ICD-10-CM is more applicable to non-hospital settings than ICD-9-CM.

September 23, 2003

The NCVHS heard testimony from RAND on the final results of the cost benefit analysis. Other groups that have also performed impact studies provided testimony on their results. These other groups included American Medical Association (AMA) and preliminary results from Blue Cross Blue Shield Association. Reactions to the RAND report were heard from AHA, AHIMA, AMA, Health Insurance Association of America (HIAA) and CMS. The Subcommittee agreed to evaluate the testimonies during their next meeting on October 28-30, 2003. Additionally, AHA/AHIMA provided final results of their joint pilot test of ICD-10-CM.

A letter, co-signed by 55 medical/surgical specialty organizations sent to the NCVHS. The organizations support the continued use of CPT and urge the Committee to confine the recommendation to the users of ICD-10-PCS to inpatient hospital services. This is a change from the recommendation to the NCVHS made in the September 23, 2002 letter.

October 2003

Subcommittee convened hearing on ICD-10-CM and ICD-10-PCS. National Association of Health Data Organizations (NAHDO), HIAA, BCBSA and CMS and the American Academy of Professional Coders (AAPC) present additional testimony. Additionally, Blue Cross Blue Shield Association presented its final report, prepared by the Robert E. Nolan Company, on the costs of replacing ICD-9-CM with ICD-10-CM and ICD-10-PCS. The Subcommittee drafts a letter to the Secretary that recommends that HHS initiate the regulatory process for the concurrent adoption of ICD-10-CM and ICD-10-PCS.

November 4, 2003

The letter drafted by the Subcommittee is reviewed, revised and adopted by the full NCVHS. The letter is mailed on November 5, 2003.