Once upon a time we marveled at the fact that Baskin Robbins had come up with 31 flavors—what a smorgasbord of opportunity. Then they branched out into seasonal flavors, regional flavors, even frozen yogurt, which vaulted them upwards into having more than 50 flavors. What a joy to behold: more is definitely better when it comes to ice cream.
Same story for television. Some of you, those that are resting comfortably next to me in a nursing home, will remember the old days when we had ABC, CBS, NBC and Channel 13 as the primary TV channel choices. Then there were 13 channels, then around 20, and now my mercenary cable providers shows me more than 700. This example is a little sketchier. More than 4 channels is definitely better. As many as 700? Well, I guess it works if you figure that they are trying to capture everyone in the world’s tastes, even those that want to watch Jersey Shore and Deadliest Catch.
So what do we make, then, of the Center for Medicare and Medicaid’s (CMS) recent announcement of the updating of the diagnosis codes that physicians use to communicate patient ailments?
In the olden days, meaning 2011, there exists a system of about 18,000 ICD-9 codes that physicians have used for 30 years to fill out those claim forms that will get rejected by our insurance carriers. The codes describe patient conditions including everything from headaches to broken bones to complex disease states. They are used to drive the reporting, tracking and payment systems of the insurance marketplace, both public and private. 18,000 codes? Surely, one would think, that is enough to cover it.
Unfortunately, 30 years is a long time so the system has become somewhat out of date. According to one source:
ICD-9 codes are now almost completely obsolete. ICD-9 codes don’t provide the necessary detail for patient medical conditions, or the procedures and services provided to hospital patients. Furthermore, the ICD-9 system contains outdated terminology, codes that produce inaccurate data, and codes that are inconsistent with current medical practice. Because of this, the ICD-9 system is not capable of producing an accurate picture of patient care in the 21st century.
OK, I’ll bite (p.s., “bite” is foreshadowing for what is to come later in this article). What in the human body has changed so much in the last 30 years that 18,000 codes can’t cover it? I’m no doctor, but unless you’re counting parts made of silicone, there are no new organs, bones or appendages of which I’m aware.
Nevertheless, in their infinite wisdom (and probably for some good reasons), CMS has published a new coding system, the ICD-10, which medical providers and insurance companies are legally required to transition to by October 1, 2013. The new ICD-10 has over 140,000 codes. Yes, you read that right: there are more than 7 times the number of codes that your doctor will now have at their disposal. As you can imagine, they are less than thrilled. Here’s a tangible example: the ICD-9 code for pressure ulcer includes 9 different codes depending on the location of the pressure ulcer. The ICD-10 coding system, however, includes 125 different codes, ranging from L89.131 to L89.152, depending on the location and depth of the pressure ulcer. I can only imagine the geo-location map required to find the spot to call out when coding. GPS manufacturers everywhere are going to be thrilled.
The New York Times wrote a hilarious article pointing out how absurd the new ICD-10 looks to a lay-person and, I hope, to most doctors. The article noted that some of the more mind-boggling codes are downright insulting: R46.1 is “bizarre personal appearance (see code),” while R46.0 is “very low level of personal hygiene (see code).” They point out others that help qualify klutzy behavior such as W22.02XA, “walked into lamppost, initial encounter” (or, for that matter, a W22.02XD, “walked into lamppost, subsequent encounter”). I am guessing that the treatment for this malady is: “Hey idiot, stop texting and walking.”
Notably there are codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting and one for hobbyists that involves a “burn due to water-skis on fire (see codes).” I’m guessing that one only happens if you are re-enacting an old episode of BayWatch.
My most favorite category is the one about bites. The NY Times notes that there are 312 animal codes in all, including separate codes for “bitten by turtle” and “struck by turtle.” (See codes.) But the huge and varied selection of 96 separate bite codes could make a vampire salivate. There are codes for initial and subsequent bites by mice, rats, squirrels and “other rodents.” I’m wondering if capybaras and hamsters feel bad about not making the specific list.
There are codes for bites by dogs and cats, naturally, but also dolphins, sea lions and orcas. Is this a big problem in our medical system? As one who lives near the Farallon Islands I can understand the myriad of shark bite codes, but parrots, macaws and “other psittacines”? I never even heard of that word before. Polly the psittacine want a cracker? You can see the full list of bite codes HERE. I swear I did not make this up, but I wish I could take credit for it. I do find it remarkable, in this age of Twilight, the Vampire Diaries and True Blood, that there are no codes for vampire bites. ICD-11 here we come.
According to the NY Times article:
The federal agencies that developed the system—generally known as ICD-10, for International Classification of Diseases, 10th Revision—say the codes will provide a more exact and up-to-date accounting of diagnoses and hospital inpatient procedures, which could improve payment strategies and care guidelines. “It’s for accuracy of data and quality of care,” says Pat Brooks, senior technical adviser at the Centers for Medicare and Medicaid Services.
By the way, the best part of the NY Times article is this paragraph:
Other coding cognoscenti spot possible hidden messages in the real codes. The abbreviation some use for the new system itself, I10, is also a code for high blood pressure. Several codes involving drainage devices end in “00Z.” Then there are two of the codes describing sex-change operations that end in N0K1 and M0J0. “You could see it ripple through the room as people said, ‘nookie and mojo!'” says Kathryn DeVault, who has been teaching ICD-10 classes for the American Health Information Management Association. “Was it purposeful? We don’t know.”
So from a practical point of view, what does this really mean to our healthcare system? Well, it probably means higher costs, which is exactly the opposite of what we are trying to achieve right now. First of all, doctors and hospitals have to massively upgrade their information technology systems to accommodate these new codes and, probably worse, alter their forms, procedures, workflows and staff knowledge. If you are among those that thinks insurance claims systems are already complex and stupid enough, brace yourself. Insurers will now have 140,000 more reasons to mess up your claim and providers will have 7 times the opportunity to bill you even more.
The American Association of Orthopaedic Surgeons (AAOS) along with 11 other healthcare organizations, recently released a study conducted by Nachimson Advisors, LLC, which suggests that CMS has underestimated the cost of implementing the ICD-10 code set. According to the study results, the implementation cost for a three-physician practice could be as much as $83,290, while a 100-physician practice might pay more than $2.7 million. (View the full study). Training clinical and administrative staff to use the new ICD-10 code set may require up to 16 hours for coding staff, 8 hours for administrative staff, and 12 hours for providers, according to the analysis. If you think it’s hard to get an appointment with your doctor now, just wait until he or she goes out for ICD-10 training.
According to that same study, the move to the ICD-10-CM will increase provider documentation activities about 15 percent to 20 percent. This translates into a permanent increase of 3 percent to 4 percent of physician time spent on documentation for ICD-10-CM. Yeah, providers are psyched. They LOVE documentation.
It turns out that other countries have already begun using the ICD-10 system. The UK adopted it in 1995 and France in 1997. Australia, Germany and Canada all use it. Canada I can understand; they clearly need those goose bite codes. I am wondering if there is a code for “burned my fingers with a Gitane while reading existentialism” that led the French to be such early adopters.
Now there’s an opportunity: country-specific ICD-10 codes. We could start up ICD-10: American Edition and include such culturally-appropriate codes as “Exploded As Result of Consuming Baconator,” “Brain Melted from Over-Viewing of Jersey Shore” and “Extreme Vomiting Due to Overexposure to Paris Hilton”. I think I have just discovered my next venture opportunity.