1. 3M Health Information Systems A “Behind The Scenes” Analysis of ICD-10 Activity in Washington, DC Richard Averill, Director Public Policy

2. 3M Health Information Systems 22 1993-ICD-10 released by World Health Organization (WHO) 1994-National Center for Health Statistics begin work on a clinical modification of the WHO ICD-10 for use in the U.S. (ICD-10-CM) -3M awarded contract to develop ICD-10-PCS 1997Draft version of ICD-10-CM completed 1998-Draft version of ICD-10-PCS completed 1998-2002-National Committee on Vital and Health Statistics (NCVHS) hold series of stakeholder meetings on ICD-10-CM/PCS 2003-Under contract with NCVHS, RAND does a study concluding the benefits of implementation of ICD-10-CM/PCS would far exceed its cost ICD-10 History

3. 3M Health Information Systems 33 2008-HHS publishes a Notice of Proposed Rule making (NPRM) setting an implementation date for ICD-10-CM/PCS of October 1, 2011 2009-HHS publishes a final rule settling an implementation date for ICD- 10-CM/PCS of October 1, 2013 2012-HHS publishes a final rule of postponing the implementation date for ICD-10-CM/PCS to October 1, 2014 March 2014-Congress passes the Protecting Access to Medicare Act of 2014 delaying the implementation of ICD-10-CM/PCS until October 1, 2015 December 2014 An attempt to included an ICD-10 delay until 2017 in the Appropriations Bill fails ICD-10 History

4. 3M Health Information Systems 44  It’s now 16 years since the U.S. version of ICD-10 was completed, five years since publication of the ICD-10 final rule, and the U.S. still has not implemented ICD-10  There will be an attempt to delay ICD-10 during next month’s debate on the extension or replacement of SGR (doc fix) legislation Bottom Line

5. 3M Health Information Systems 55  Virtually the entire healthcare industry supports the on time adoption of ICD-10 in October of 2015  The only substantive opposition is from the physicians led by the AMA lobbying machine ICD-10 Opposition

6. 3M Health Information Systems 66  Unlike the EMR and e-prescribing requirements, ICD-10 is an unfunded mandate  ICD-10 follows a long series of mandated changes  Too much change  ICD-10 is viewed as the Federal government’s attempt to take over American medicine  Big brother getting the information it needs to take control  ICD-10-PCS may be a long term threat to the AMA’s CPT franchise Why is the AMA Opposed to ICD-10?

7. 3M Health Information Systems 77  No matter how irrational the alligator vs crocodile or burning waterski examples are, repeated over and over those sound bites of misinformation are effective  The timing was perfect  Implementation was scheduled 8 weeks before mid-term elections  The rollout of ACA website had been a massive failure  If the rollout of ICD-10 caused an interruption in Medicare payments, voters would take it out on the incumbents  Congress wanted AMA support for the SGR bill (which did not happen)  ICD-10 was germane to the SGR bill  The “doc caucus” in Congress supported an ICD-10 delay Why was the AMA able to get an ICD-10 Delay in Last Year’s SGR Legislation?

8. 3M Health Information Systems 88  Opponents of the ACA believed failure to implement ICD-10 would reduce the effectiveness of the ACA  Some Republicans believed that the Democrats would not risk having an ICD-10 implementation failure before the election, so it was going to be delayed by the Obama Administration anyway  ICD-10 was characterized as a big government take over of American medicine  Proponents of ICD-10 were not well organized Why was the AMA able to get an ICD-10 Delay in Last Year’s SGR Legislation? continued

9. 3M Health Information Systems 99  Puts out a bewildering barrage of ICD-10 misinformation sound bites  Facts don’t matter  Extensive resources available  Can enlist vocal state medical society and specialty society spokespersons The AMA Public Relations and Lobbying Machine

10. 3M Health Information Systems 10 RESPONSE:  Physicians are only impacted by the diagnosis portion of ICD-10  Physician Payment is almost entirely based on CPT codes  Physicians primarily use the codes relevant to their specialty not the totality of codes  Ophthalmologists will primarily only use the eye codes  An individual only uses a small fraction of the 470,000 words in the dictionary  Out of touch with today’s digital world  Google is not difficult to use even though a search of the term ICD-10 yields 13 million matches  There is a free app to look up ICD-10 codes  More specificity lessens coding challenges and administrative burden  Imprecise codes in ICD-9 create coding ambiguities and audit disputes  More detail in the codes reduces payer requests for additional information ICD-10 Myth #1: The large increase in the number of codes makes ICD-10 more complex and difficult to use

11. 3M Health Information Systems 11 RESPONSE:  63% in the increase in the number of diagnosis codes is due solely to the reporting of laterality and the stage of treatment of an injury  More anatomic specificity further contributes to the increase in the number of codes  Much of the remaining increase is due to requests from medical societies ICD-10 Myth #2: The large increase in the number of codes creates a burden by requiring the coding of clinically irrelevant detail

12. 3M Health Information Systems 12 RESPONSE:  This is exclusively an external cause of injury issue (alligator vs crocodile bite)  Except for few external cause of injury codes related to medical misadventures (surgery on wrong body part), Medicare does not require the reporting of external cause of injury codes  Payers like workers comp who require a separate reporting of external cause of injury codes will require a separate data submission if the needed information is not available in the codes  Codes that are virtually never coded do not make ICD-10 more difficult to use  The word “floccinaucinihilipilification” does not make English more difficult to use ICD-10 Myth #3: Because there are isolated ICD-10 codes that will rarely be used, ICD-10 is riddled with unnecessary detail

13. 3M Health Information Systems 13 RESPONSE:  ICD-10 was developed using the same process used for ICD-9  Open forum in which all stakeholders have a voice  Extensive input from physician specialty societies ICD-10 Myth #4: ICD-10 was developed by out of touch bureaucrats and is not relevant to physicians

14. 3M Health Information Systems 14 RESPONSE:  WHO is scheduled to release of ICD-11 in 2017  For the U.S. 2017 is just the beginning, not the end  A CM version must be developed to meet U.S. needs (8 years for ICD-10)  A regulatory process of proposed rules and comment periods is required (11 years for ICD-10)  A time period for industry preparation is required (3 years plus 2 one year delays for ICD-10)  Based on the ICD-10 timeline, ICD-11 would not be implemented until 2041  A report commissioned by the AMA Board of Trustees, recommended against waiting for ICD-11 ICD-10 Myth #5: Skip ICD-10 and wait for ICD-11

15. 3M Health Information Systems 15 RESPONSE:  A study commissioned by the AMA estimated the cost of conversion to ICD-10 for a small physician practice to be $22,560-$105,506  Subsequent studies have resulted in dramatically lower estimates  The American Academy of Professional Coders (AAPC) survey of small physician offices reported the cost of conversion to be $750 per physician in the practice  A 3M study estimated the cost of ICD-10 conversion for a three physician practice to be $1,960-$5,900  A PAHCOM survey of small physician practices to be released next week will report ICD-10 conversion cost consistent with the AAPC and 3M estimates ICD-10 Myth #6: The cost of implementing ICD-10 is prohibitive for small physician offices

16. 3M Health Information Systems 16  The market has responded  ICD-10 educational materials are now readily available for a nominal cost  Specialty specific superbills can be downloaded at no cost from the internet  Many software system vendors are providing ICD-10 system updates at no additional cost  The adoption of electronic health records by physician practices has further facilitated the transition to ICD-10 Reasons for Low ICD-10 Conversion Costs

17. 3M Health Information Systems 17 RESPONSE:  There is no rational response ICD-10 Myth #7: ICD-10 will give the Federal government the information it needs to take over American medicine

18. 3M Health Information Systems 18  Rarely mentioned by the AMA  CPT is really not much better than ICD-9-CM procedures  Both are loosely organized lists of codes  ICD-10-PCS is a modern multi-axial system with comprehensive definition of terminology  Although ICD-10-PCS substantially increases the number of procedure codes, it is based on only 3,134 standard procedure attributes  Each code is a unique combination the standard procedure attributes  The majority of procedure attributes are anatomic sites and devices  Learning the system involves becoming familiar with the standard procedure attributes A Word About ICD-10-PCS

19. 3M Health Information Systems 19  Each CPT code can have up to 4 modifiers  There are 31 Level I modifiers like bilateral and 39 Level II modifiers like left/right  The 9,963 CPT codes plus up to 4 modifiers each with 70 possible values creates a limitless number of unique codes CPT Actually Contains a Limitless Number of Codes

20. 3M Health Information Systems 20  Virtually the entire healthcare industry wanted ICD-10 to move forward  There was no central voice for ICD-10 supporters  Positive facts about the benefits of ICD-10 were no match for negative sound bites  Supporters of ICD-10 had to be prepared to aggressively rebut the AMA misinformation  A year long Hill strategy had to be developed and implemented  A coalition of ICD-10 supporters was needed What Did We Learn From Last Year’s Delay?

21. 3M Health Information Systems 21  An advocacy group whose mission is to promote the adoption of ICD-10 on October 1, 2015  The Coalition now has a complete cross-section of the healthcare industry as members including providers, payers, vendors, device manufacturers and the HIM community.  The executive committee is comprised of 3M, AHIMA, AHA and national BCBS.  The Coalition website promotes positive ICD-10 stories and rebuts misinformation  www.coalitionforICD10.org  Focuses on ICD-10 news especially as it relates to CMS and Hill activities. Coalition for ICD-10 was formed

22. 3M Health Information Systems 22 Coalition Members: Advanced Medical Technology Association (AdvaMed) Altegra Health American Health Information Management Association (AHIMA) American Hospital Association American Medical Billing Association (AMBA) American Medical Informatics Association (AMIA) America’s Health Insurance Plans (AHIP) BlueCross BlueShield Association College of Healthcare Information Management Executives (CHIME) Healthcare Financial Management Association (HFMA) Healthcare Leadership Council Health IT Now Coalition Leidos Health Medical Device Manufacturers Association (MDMA) Medtronic Nemours Children’s Health System Premier, Inc Professional Association of Health Care Office Management (PAHCOM) Roche Diagnostics Corporation Siemens Health Services 3M Health Information Systems WellPoint ICD-10 Coalition Members

23. 3M Health Information Systems 23  Held meetings with the administration members of Congress and their staffs  Promoted positive stories on the benefits of I-10 and  Conducted grassroots out reach efforts encouraging individuals to contact their members of congress  Next week the Coalition will be holding an ICD-10 briefing for Hill staff  Speakers will include small physician offices discussing ease of transition to ICD-10  PAHCOM survey of ICD-10 transition costs for small physician offices will be released  Press is invited to briefing Coalition Activities

24. 3M Health Information Systems 24  Survey of ICD-10 Implementation Costs in Small Physician Offices Blanchette, Averill, Bowman, February, 2015.  The Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments Mills, Butler, Averill, McCullough, Fuller and Bao, February, 2015.  Cost of Converting Small Physician Offices to ICD-10 Much Lower than Previously Reported Kravis, Belley, Smith, Averill, November 2014.  Misperceptions, Misinformation, and Misrepresentations: The ICD-10-CM/PCS Saga Averill, Butler, June, 2013.  There are Critical Reasons for Not Further Delaying the Implementation of the New ICD-10 Coding System Averill, Bowman, July, 2012. Recent 3M Studies on ICD-10 Implementation Issues Published in AHIMA Journal

25. 3M Health Information Systems 25  Follow the I-10 coalition website to keep up to date  Participate in the CMS end to end I-10 testing  Be a vocal advocate for ICD-10  Be prepared to write to your Congressman  The Coalition website will have an automated process for submitting an ICD-10 support letter to members of Congress  During the March SRG debate the Coalition plans to bombard congressional offices with I-10 support emails, letters and phone calls What can you do help?

26. 3M Health Information Systems 26  The momentum to prevent another delay has really gained strength but the AMA remains a formidable adversary  Aggressive Hill activity during February and March will be essential for preventing another delay Conclusion