Friday, October 9, 2015
ICD-10 and inflation of codes
October first has come and gone. For many of us, this date had little significance beyond the promise of cooler weather, lovely autumn colors, and the invasion of neighborhoods with giant inflatable Halloween decorations. While these decorations are fascinating to me, the do cause me to ponder the enormous gulf between my taste and that of my neighbors.
October 1, however, was a huge day to the medical community. It is a day that will live in infamy. It is the object of dread, of diaphoresis, of doom. October 1 was ICD-10 day. This view was further bolstered when I went to the CMS (Government Medicare) website, there was actually a doomsday countdown timer at the top of the page. Just looking at this made me anxious.
For those still unaware (perhaps looking through catalogs for gigantic inflatables for President's Day), ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system. This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible). This change should be cause for great celebration, as ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar. Really.
But, as Abe Lincoln may have said, better the devil you know than the one you don't. We all got used to the stupidity of ICD-9, and, like the crazy neighbor who puts huge inflatables of the Santa Maria in their yard on Columbus Day, we learned to tolerate its eccentricities. It's better than having an axe murderer or hospital administrator in that house. Unfortunately, the folks over at ICD Inc. got overly zealous in their desire for completeness, increasing the number of codes from the 17,000 in ICD-9 to over 90,000 in ICD-10. It's as if that neighbor not only added the Nina and Pinta to their lawn, but also inflatable natives infected with smallpox along with a mural depicting the skyline of Columbus, Ohio. It seems a bit over the top.
Anyone paying attention to this subject knows of the ludicrous codes now available to the medical community (being bit by a duck while wearing a thong, being bit by a duck that is wearing a thong, being bit in the thong by a duck, being crushed by a giant inflatable while eating kale, etc.), so I won't go into those now. These give health wonks hours of entertainment, for which we are all grateful. But there is a much bigger, more serious set of problems brought about by the onslaught on the medical community by the ICD hordes.
Before I go into this, however, let me state that, because I no longer live in the insurance world (doing direct primary care), I do not bear the brunt of this apocalypse. Yes, we are inconvenienced by the need to submit ICD-10 codes for consults, labs, and procedures, but that is about the extent of it. I was tempted to get snarky here and lord this fact under my suffering colleagues, but thought better of it. While this may be a boon to the growth of alternative practice models like DPC, gloating over it seems cruel. Having lived in the land of insurance and codes for 18 years, the prospect of converting over to ICD-10 even now gives me cold sweats.
There are 2 main problems with this conversion from 9 to 10. The first problem is that, as I've written before, codes are the product produced by health care businesses. Health care providers (doctors, hospitals, and the rest) are paid for producing problem (ICD) codes and matching them with procedure (CPT and E/M) codes. This is the product they sell to their true customer: the third-party payers. Submission of the wrong codes has 1 main result: no payment. Codes are the lifeblood that carry the money to medical providers, and so changing those codes threatens the financial viability of medical businesses, large and small. Get this conversion wrong, and you don't make enough money to stay in business.
Now, because there has been enough time, and with the ubiquity of EMR systems centered on billing, the ironic heroes in this may be the EMR vendors. This should minimize the overall damage to the financial survival of medical businesses. Despite this fact, the conversion of codes strikes at the very heart of our health care business model.
The bigger issue here is the fact that, while they are the ones saddled with the expense of conversion and the ones facing the financial risk of not doing so, there is no obvious advantage to the doctors themselves to be making this transition. ICD coding is a billing nomenclature that does not give any apparent benefit to patient care. Codes don't help us make diagnoses, nor do they improve doctor-patient relations. In fact, it's very likely that this transition will lessen the ever waning focus on the patient while providers are obsessing on getting the code that will get them paid. The only positive most medical practitioners will see out of this conversion is getting rid of ICD-9.
Perhaps, like the 30-foot Santa riding a motorcycle which exploded in my neighbor's lawn last December, my fears are overinflated. The reality is that October 1 will come and go without the world caving in on the medical community. But my fear is that this is one more way our system is alienating and frustrating its workforce. This is, in my view, the more serious problem that will soon overtake all others. It is possible to still love practicing medicine, even in the screwed up system we have. But the number of doctors, nurses, and other providers who are reaching their limit is growing quickly, as witnessed by the number of phone calls and emails I am getting from doctors looking for an alternative.
Perhaps that's a good thing, as the misery created by ICD-10 may drive the system toward a better model. But I don't imagine the ICD corporation and its minions are pushing this on us with this intent. Someone somewhere thinks this makes sense.
Just like my neighbor who thought it made sense put a giant inflatable pregnant woman in front of their house for Labor Day.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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