Is There a Doctor in the House?

A physician laments that physicians were not invited to participate in the AHIMA/ACDIS CDI Practice Brief.

For steadfast readers of ICD10monitor and attentive listeners to Talk Ten Tuesdays, news of the recent release of the updated industry practice brief on how to achieve a compliant query – developed collaboratively by the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Integrity Specialists (ACDIS) – seemed to be omnipresent.

Yet it wasn’t until last Tuesday, during the live broadcast of Talk Ten Tuesdays, produced by ICD10monitor, did I come to appreciate that something may have been missing from the updated version.

My ah-ha moment came as I listened to my guest cohost during the broadcast, Dr. James Kennedy, patiently explain to listeners that since the practice brief was authored by AHIMA – one of four ICD-10-CM/PCS Cooperating Parties, along with the American Hospital Association (AHA), the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics – it was deemed an “industry standard” for query practice that now will be quoted by government accountability agents such as the U.S. Department of Justice (DOJ), the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), and other auditing entities, like the Recovery Auditor Contractors (RACs), when addressing allegations of fraudulent “upcoding.” 

In my recent article on this topic, I reported on how the DOJ is prosecuting Kaiser Permanente for what the agency has labeled “leading queries” rendered in a manner violating the provisions of previous such briefs, published in 2013, 2016, and 2019 (https://icd10monitor.medlearn.com/ahima-releases-new-guidelines-for-queries/)  

In a subsequent conversation, Kennedy wondered aloud why the American Medical Association (AMA) – the lead creator, maintainer, and copyright holder of the Current Procedural Terminology®, the HIPAA-sanctioned transaction set required for all physician and outpatient facility billing – was not privy to participating in the drafting of the document, especially since AHIMA proposes that anyone negotiating CPT®-applicable documentation content with providers would be accountable for the industry standards that they are promulgating with this 2022 update.

“If doctors are to be investigated using parameters established by this brief, why wasn’t the AMA invited to codevelop and coauthor?” questioned Kennedy, considered to be a recognized and highly respected authority on CDI.

According to Kennedy, this is not the first time the AMA or other physician groups have been excluded from comanaging a HIPAA-required transaction set physicians are required by law to follow. 

For years, according to Kennedy, diagnosis codes have been governed by the Centers for Disease Control and Prevention (CDC), a U.S. government agency answering to the HHS Secretary, not a physician group whose literature determines what clinical language physicians use in their day-to-day medical decision-making.

In addition, noted Kennedy, official advice published in the Coding Clinic for ICD-10-CM/PCS governing physician diagnosis assignment is written by the four previously mentioned Cooperating Parties, none of which are a physician group – whereas physicians can only offer suggestions, not exercise control over the final decisions. Both agencies conduct their business without allowing the public to witness their decision-making or know of their rationale for making the choices they make, asserted Kennedy. 

In response, the AMA House of Delegates passed a resolution in 2015 that it advocates “for a group with strong physician participation to be the 5th Cooperating Party for ICD-9-CM and ICD-10-CM, with equal power of the current four Cooperating Parties in the planning, interpretation, and deployment of ICD-9-CM, ICD-10-CM, and future ICD systems.” The resolution also suggested that HHS solicit nominees for specific groups to serve in that role.

“At the AMA interim meeting later that year, the AMA recommended that the American Academy of Professional Coders (AAPC) be added as the 5^th Cooperating Party to serve as the voice of physicians in managing ICD-10-CM/PCS, yet CMS denied this request due their perception that the AMA was advocating the AAPC to be part of the ICD-10-CM Coordination and Maintenance Committee, not as a Cooperating Party,” Kennedy claimed.

“Everyone remembers how the AMA vigorously opposed the ICD-10-CM transition in 2015 due to its additional documentation and quirky terminology that are not used in physician literature, such as ‘functional quadriplegia,’ ‘pulmonary insufficiency,’ ‘initial encounter’ to mean ‘active treatment phase,’ and ‘subsequent encounter’ to mean ‘healing phase,’” Kennedy added. 

“Imagine how resistant physicians will be when AHIMA and other entities push ICD-11-CM’s implementation and its extremely detailed documentation requirements if physicians are not coequal with the CDC, CMS, AHA, and AHIMA in determining how it is structured, how coders can reasonably interpret clinical circumstances to govern code assignment, and how restrictive billers can be in negotiating with physicians what medical record documentation is required to submit a clinically accurate and compliance code,” warned Kennedy, in a written statement to ICD10monitor. 

Kennedy said he was present at the 2022 AHIMA House of Delegates meeting in Columbus, Ohio, where he heard complaints of how physicians do not respect health information management (HIM) professionals. He believes that part of the reason for such is that AHIMA has not bridged gaps with physicians in easing the administrative burdens inherent to ICD-10-CM code assignment, evidenced by this 2022 proposed query practice brief written solely by coders and nurses and the “arcane communication constraints whereby billers have to play twenty questions” with physicians to obtain the documentation that fits ICD-10-CM’s official terminology, conventions, guidelines, and advice. 

“Is ICD-10-CM/PCS truly a joint effort between physicians and coders that assures the integrity of the ICD-10-CM/PCS administrative data set, or are the rules governing ICD-10-CM/PCS another administrative burden imposed by nonphysicians that adds to the cost of healthcare delivery in the United States and promotes burnout?” Kennedy asked.

The question remains: will AHIMA invite the AMA to coauthor this 2022 Query Practice Brief? I hope so.