The March C&M meeting: A view from the other coast

March 23, 2018 / By Rhonda Butler

Like most of you who participated in the ICD-10 Coordination and Maintenance Committee held last week at CMS headquarters in Baltimore, I watched the live webcast on YouTube. I also presented the addenda portion of the ICD-10-PCS meeting via telephone, as part of the work I do under contract to CMS. Travel in March often means weather-related drama: A missed connection, a cancelled flight, an extra night away in some random place notable only for the fact that it isn’t Oregon. This year has been a perfect example of why the East Coast and March are not a winning combination.

I think the C&M webcast meetings are wonderful, and not just because I am a home body. They allow me to listen more closely to the specifics of the presentations and the comments on the proposed coding options. This is an important part of my job, and I can do it better from a distance. It also lets me take in the bigger picture. Some “big picture” observations follow. Read on if you feel like hanging out with my inner anthropologist.

Documentation and coding continue to be a dog chasing its own tail.

The first ICD-10-PCS presentation was a request for new codes to capture a tumor ablation technique. It uses electrical micropulses that cause the cells to self-destruct (picture each little cell is a Martian brain in Mars Attacks and the micropulses are Slim Whitman yodeling). Naturally, the proponents of this technique want to collect larger scale data on how well it works, and they want new ICD-10 codes to do their data collection. But here is the rub: It is not clear that the technique, called Irreversible Electroporation (IRE) is clearly documented as such in the operative report. And if it’s not documented, the coder doesn’t know this technique was used, and therefore cannot report the new code. The presenter’s response to this concern was, “We are looking to you for a code to document to. If we have a code, then we know what we should be documenting to.” You could practically hear the coders in the audience thinking, Really?! Is that how it works? Don’t we wish it were that easy! Sue Bowman, representing AHIMA, responded that she was not a proponent of the “If you build it they will come” philosophy of maintaining a classification. Well said, Sue! The existence of a code doesn’t automatically produce the necessary documentation to support assigning the code. If it did, we wouldn’t need CDI programs, right?

This audience no longer cares about the number of codes (Hurrah! Hurrah!).

In more than one instance, the audience’s response to the prospect of creating a large number of new PCS codes by adding detail to the tables was, basically, no one cares anymore. That is such sweet music to the ears. During the run-up to ICD-10 implementation, it seemed like half my time was spent trying to persuade people that the number of codes don’t matter— month after month I would blog on and on— “no one needs to memorize codes, the increased number will not make coding more difficult, and in many cases (good news!) they actually make it easier”—till I could just barely stand to write that next blog. As Sue Bowman mentioned in the C&M meeting, about five years before implementation, the Cooperating Parties (plus 3M as PCS maintenance contractor) undertook what I called, with tongue firmly in cheek, “streamlining.” Basically, we took a virtual machete to many of the PCS tables, hacking out whole levels of detail, like specific body parts in the root operations Insertion, Removal, and Revision, and approaches all over the place. It got the number of codes down, but unfortunately it didn’t make a dent in the whining about number of codes. And doubly unfortunate is that the “streamlining” years cost us in the completeness of the system, and we have been paying for it ever since. A sizeable proportion of the codes added since implementation are the result of putting necessary detail back into the tables. Compared to the systematic population of the tables before the “streamlining”, putting detail back in is now a pretty hodgepodge affair.

The smaller the live audience, the more informal (and voluble) the live audience.

I’m not the only one who has discovered the benefits of virtual attendance at C&M. The live audience for the C&M meeting has been steadily shrinking over the years, and the addition of the CMS YouTube channel pretty much clinched it. These days the live audience typically consists of three types of attendees: 1) the presenters and their retinue (who may only stay for their portion of the agenda); 2) the spokespersons from AHA and AHIMA (aka Nelly Leon-Chisen and Sue Bowman), who, as members of the Cooperating Parties, have an express obligation to represent their membership and comment on the proposed changes; and 3) a few remaining stalwarts who come to every C&M meeting. Now, I am all for public engagement in the federal regulatory process—keeping the ICD-10 classification up to date is a collaborative process, and many dedicated, thoughtful people give their time and energy to the public good in this way. However, I can’t help noticing that some of the remaining audience members increasingly feel the obligation to stand up and tell us how they feel about every proposal, even if all they say is “I agree with Nelly.” After three or four people in a row stand up to say, “I agree with Nelly,” I confess to feeling a bit irritated. What if everyone on the phone raised their hand with the operator simply to say, “I agree with Nelly”? How long would each topic on the agenda take?

On the other hand, they did go to all the trouble to get to CMS headquarters, braved the weather, had their car checked for contraband, had their identity verified, so maybe I should not begrudge them unlimited access to the microphone. And who am I to talk anyway—what is a blog but a turn at the microphone?

Rhonda Butler is a clinical research manager with 3M Health Information Systems.

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