ICD-10 isn’t just the problem, it’s also the symptom

acp new logoA guest column by the American College of Physicians, exclusive to KevinMD.com.

By now, all of you are waist-deep in ICD-10. So far, in my practice it hasn’t been the alphanumeric Armageddon that many feared, but I will reserve final judgment until we’ve gotten through a few billing cycles. Even if it goes the way of “Y2K” and isn’t as bad as anticipated, we will still end up having spent many hours and dollars adapting to the new coding system, with little or no positive impact on the care that we deliver to our patients. (For a slightly different view, I refer you to my friend Dr. Scott Manaker’s recent commentary in the Annals of Internal Medicine.)

As stressful as the process was, it also had its amusements. Physicians’ fighting to keep ICD-9 was one of them. Perhaps those fifth digits weren’t so bad after all, some thought. It reminded me of Linus Van Pelt in “A Charlie Brown Christmas,” where he said, “I never thought it was such a bad little tree. It’s not bad at all, really. Maybe it just needs a little love.”

At an ICD-10 training session this summer, I heard that one reason for moving to ICD-10 was that we were running out of codes. I don’t know about you, but I never sat in front of my EHR wishing we had more codes. A more striking discovery was that the use of the International Classification of Diseases codes for physician payment is a uniquely American phenomenon.

Our payment system is an example of “American exceptionalism” of which we shouldn’t be proud. The impact of ICD-10 implementation on every facet of U.S. health care delivery should be another wake-up call for us to look at our absurdly complicated payment “non-system.” It’s time to consider alternatives that make getting the diagnosis right more important than selecting the correct code.

While we’re at it, let’s finally fix the penalty on primary care that is a direct result of our current system. A root cause of this inequity is that with a couple of exceptions, physicians are paid for face-to-face encounters at a time when an increasing amount of physician work occurs without the patient in the room.

One proposed solution is seemingly simple: Pay more for evaluation and management (E/M) codes. That sounds good, except it doesn’t address the non-face-to-face issue that I just described, unless one wants to assume that the E/M raise will cover the cost of those uncompensated services. However, isn’t that very assumption a big reason for the current mess?

Others suggest that insurers start paying for existing codes for non-face-to-face services such as telephone calls and anticoagulation management. That gets us closer to truly covering the care delivered, but for each of these codes there will be more claims to submit (and chase), requiring more ICD-10 codes.

This approach gives me flashbacks to internship, where every supply item, such as IV needles and saline bags, had a sticker to be placed on a “bingo card” at the patient’s bedside that was used for billing. Do we want to promote a “bingo card mentality” and end up like other professionals, whose itemized statements include every minute, photocopy, and postage charge?

What about alternatives to encounter-based payment? Should we adopt a per-patient per-month charge to cover services provided outside the face-to-face visit? This would be risk adjusted (probably using ICD-10 codes, at least until natural language processing can scan a note and figure out severity of illness) so that a healthy 30 year old’s payment is less than that of a 75 year old with COPD and diabetes. Medicare’s chronic care management code is a step in that direction, but unfortunately, the rules are too complicated for the code to be of use to many physicians. Hopefully, that will be fixed.

How about going a step further and looking at more comprehensive types of payment? The “slippery-slopers” in the audience will say that is a step towards capitation, to which I would respond that it could be, but if so, is that such a bad thing. Quality measures, while not perfect, can serve as checks and balances against short-changing patients to game the system. Physicians have more access to their own data now than they did in the 1980s and 90s, which levels the playing field when working with insurers on global payment, gainsharing, and other non-encounter-based payment models. (A recent Annals article describes eight basic payment methods and is worth reading for an understanding of the options.)

The CMS is asking many of these questions, as demonstrated in its Proposed Rule for Calendar Year 2016. The American College of Physicians (ACP) submitted a comment letter in response where it urged the agency to “recognize non-face-to-face services that enable primary care physicians who provide chronic disease management and care coordination to provide valuable and timely care to their patients.”

Finally, should we accelerate the move from paying for services based on “parts and labor,” which is what the resource-based relative value scale (RBRVS) does, to paying based on value to patients? Take a 99213 visit for follow-up of a couple of stable conditions and compare it to a 99213 for an acute problem whose workup leads the diagnosis of a curable cancer. On paper, both have similar resource inputs – physician work (time and intensity) and practice expense (clinical staff time and supplies) mainly – but do they really have similar values? Seeing a sick patient today or tomorrow pays the same as seeing that patient after a week-long wait. Those are the “rules” of the RBRVS system that even a “perfect” RUC composition and process won’t change. Should “what’s it worth to patients and society” be as important, or even more important, than “what does it cost”?

Think about this the next time you have to look up the code for “sucked into jet engine, subsequent encounter.”

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Image credit: Shutterstock.com

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