Blog | Wednesday, April 16, 2014

Why does ICD-10 feel so bad?

Things have been heating up in the controversy over the implementation of ICD-10. First, a quick primer for those of you who have not been following this.

The “ICD” in ICD-10 stands for International Classification of Diseases. The “10” refers to the version of the taxonomy, which is maintained and revised periodically by the World Health Organization and “is the standard diagnostic tool for epidemiology, health management and clinical purposes.”

Although conversion from the ICD-9 standard, which is still in use in the U.S., to ICD-10 is causing a major kerfuffle, it is important to note that ICD-10 has been around since 1990, and the WHO is poised to release ICD-11 in 2017. The 9th and 10th editions differ primarily in their specificity of coding, with the 10thdifferentiating between acute and chronic states of the same condition, left and right sided findings, initial and ongoing treatment, etc. The net result, of course, is that there are a lot more ICD-10 than ICD-9 codes to describe the full array of human disease and unfortunate mishaps, even though humans and the things that befall them have not gotten much more complicated since 1990.

The current controversy arises from the fact that the Centers for Medicare and Medicaid Services (CMS) has mandated that hospitals and physicians submit their bills using the new codes as of Oct. 1, 2014, effectively creating a new national standard for reimbursement determinations. The timing of the change-over means that doctors and hospitals must implement this as they simultaneously struggle with new quality mandates and IT meaningful use requirements. No wonder, then that the AMA has renewed its call for a delay in implementation, citing, among other things, a study (that it funded) that estimates that it will be financially “disastrous” for physicians to implement ICD-10.

Although these are legitimate concerns, I think the objections that many physicians have to ICD-10 goes deeper than having to change some old habits of how we write our notes and drop our bills. I think it has to do with a fundamental disconnect about the role of “documentation.”

As students and trainees, we were taught that the medical record is a tool for patient care. That it is intended to share information with other providers; or create a narrative over time, so that a patient’s progress (or lack thereof) can be observed; or provide a repository of reference information that may serve a future, as yet unidentified, clinical need. Yes, including enough information in our records for others to summarize into ICD-10 codes based on hospital documentation, or selecting the codes ourselves for office-based encounters, serves those ends. But the problem is that most clinicians believe that they can achieve the fundamental goals of clinical documentation without the constraints and complexity of ICD-10 coding.

Here is the real problem. Just as I pointed out with EMRs, we have accepted a system that pays doctors and hospitals for “doing stuff.” Naturally, those paying the bills want to make sure that the stuff they are paying for is both appropriate and actually getting done, and have demanded that we “document” both. The language chosen for that exchange (we tell you what we did, and you pay for it) is an epidemiologic classification scheme that was not designed for that purpose. Is it any wonder that doctors hate it?

Despite the disconnect, ICD-10 is coming and my organization, North Shore-LIJ, is moving forward with its ICD-10 education. In the meantime … What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.