Healthcare reform: there's a code for that

[LawBeefaroni]

While Washington threatens to derail the economy over the healthcare spat, healthcare marches onward. In October, 2014 Medicare (and thus everyone else in the US) will be going live with the new ICD-10 coding system. In short, the International Statistical Classification of Diseases (ICD) is a worldwide standard of classifying medical conditions and diagnoses. Every medical claim includes an ICD diagnosis code. Canada, Australia, and many other countries are currently using ICD-10. The US healthcare system is currently using ICD-9 and the move to ICD-10 is intended to yield greater reporting accuracy and even higher resolution for health data mining. How fine is the resolution?


Well, here are some codes I was alerted to in a recent meeting:

• W22.02X - "Walked into lamppost"
• W16.221 - "Fall in (into) bucket of water causing drowning and submersion"
• T71.231 - "Asphyxiation due to being trapped in a (discarded) refrigerator, accidental"
• T71.232 - "Asphyxiation due to being trapped in a (discarded) refrigerator, intentional self-harm"
• T71.233 - "Asphyxiation due to being trapped in a (discarded) refrigerator, assault"
• T71.233 - "Asphyxiation due to being trapped in a (discarded) refrigerator, undetermined"
• v91.07 - "Burn due to water-skis on fire"
• v97.33 - "Sucked into jet engine"

And of course, the one that you hope you never have to use:

• v80.730 = "Animal-rider injured in collision with streetcar"

[YellowKing]

Yeah, we have signs around the building that say, "Pecked by a chicken? There's a code for that!" And yes, there is a code for being pecked by a chicken.

We've had fun making up our own codes, like "Mauled by rabid wolverines."

[stessier]

We've had fun making up our own codes, like "Mauled by rabid wolverines."

Accidental, intentional, assault, or undetermined?

[funnygirl]

Coder's mantra: "Code to the highest degree of accuracy."

[LordMortis]

W22.02X - "Walked into lamppost"

Texting and walking - raising the cost of Health Insurance since 2000.

(Of course I drove into a lamp post in a parking lot once and had to get stitches for it. But this was done when texting was done by pagers. I was stupid idiot for reasons having nothing to do with electronic devices)

[Arcanis]

Try this on for size. We had a very similar situation to the 80.730. There was a news story from here Friday about 2 guys riding horses along a stretch of road that has been slated to be part of I-49 since I was born, so obviously not a "country" road as it is 3 lanes each direction with buildings between north and south lanes. These 2 guys decided to "drag race" their horses and ended up being a hit and run. They ran into a car at an intersection, causing severe damage to the car and most likely injuring the horse. Then proceeded to run off on the horses.

[Dr. Sugardaddy]

We'll, there's accuracy and precision, but there's also a nightmarish level of bureaucracy. If you bang your head on a kitchen cabinet and open your scalp to the tune of a few stitches, the ICD9 code is relatively straightforward and limits itself to the nature and location of the injury. In ICD10, providers will have to code (each line item has a separate code, bear in mind)

-the nature of the injury;
-the location of the injury;
-where the injury occurred (in this case, at home in the kitchen, which each could be a separate code);
-in some cases, the activity being performed while the injury occurred (e.g., reaching up into a cabinet instead of bending down to open a cabinet--each with separate codes).

And that's just for a simple scalp injury. The comorbidities around mutiiple chronic illnesses or other complex diseases and injuries are going to take a lot of learning to understand and use correctly.

Isn't the rest of the world moving to ICD11 in 2015?

[Scuzz]

My wife is studying to take the ICD-10 test. I will have to quiz her with those codes.

[LawBeefaroni]

We'll, there's accuracy and precision, but there's also a nightmarish level of bureaucracy. If you bang your head on a kitchen cabinet and open your scalp to the tune of a few stitches, the ICD9 code is relatively straightforward and limits itself to the nature and location of the injury. In ICD10, providers will have to code (each line item has a separate code, bear in mind)

-the nature of the injury;
-the location of the injury;
-where the injury occurred (in this case, at home in the kitchen, which each could be a separate code);
-in some cases, the activity being performed while the injury occurred (e.g., reaching up into a cabinet instead to bending down to open a cabinet--each with separate codes).

And that's just for a simple scalp injury. The comorbidities around mutiiple chronic illnesses or other complex diseases and injuries are going to take a lot of learning to understand and use correctly.

Isn't the rest of the world moving to ICD11 in 2015?

Will it lead to safer kitchen cabinet design when statistics show that 85% of kitchen cabinet scalp lacerations are caused by bending down to open a cabinet? I don't know myself but supposedly that's why we have such detail, to learn from the data. OTOH I predict a lot of fudging on the details when the actual answer isn't known or isn't communicated well, say by patient bleeging profusely from their head.

[Freezer-TPF-]

Based on anecdotal evidence, kitchen cabinets would be safer if they had no doors at all for me to whack my head on. But then my dishes and glasses would get dusty.

[stessier]

OTOH I predict a lot of fudging on the details when the actual answer isn't known or isn't communicated well, say by patient bleeging profusely from their head.

There is only so much we can do. I think you'll agree that if we have to start error proofing for bleeging injuries, we're never going to get anywhere.

[Archinerd]

For some reason this thread makes me want to play Advanced Squad Leader.

[LordMortis]

For some reason this thread makes me want to play Advanced Squad Leader.

Or Starfleet Battles... Or some of the old Avalon Hill Bookshelf Games.

[Isgrimnur]

It's turtles all the way down.

[Kraken]

At the mercy of Medicare's codes

The health care industry speaks in code. Each of this country’s 9,707 medical procedures and services has a unique five-unit code of numbers or letters, plus a concise description. These CPT codes, developed and licensed by the American Medical Association over the past four decades, plus Medicare’s own set of codes, have become the nation’s shorthand for medical services and billing.

Yet doctors are not ethically bound to tell you the codes and costs upfront. And Medicare representatives are trained not to tell you the codes and not to help you without the codes

...

Diane has reason to fear cancer. Her mother and daughter had double mastectomies, and she has dense-tissue breasts. Her doctor, Kristen Zarfos, director of St. Francis Hospital’s Comprehensive Breast Health Center in Hartford, put her on a screening schedule years ago, alternating a mammogram and a breast MRI every six months.

Last year, her first on Medicare, the government covered both procedures. Diane didn’t pay a penny for the MRI. But in April, Diane says Dr. Zarfos’s assistant called with bad news. St. Francis’s billing department said Medicare had changed its policy and would not pay for this year’s MRI. Diane could get the MRI, the assistant added, but she’d have to pay $1,500 for it out of her own pocket. (I eventually learned that St. Francis had billed $5,548.43 for Diane’s previous MRI, but it was only paid $289.54 by Medicare.)

With nothing in writing from the hospital explaining the policy change, the bewildered family contacted the Center for Medicare Advocacy, and a person there reached out to me to do some checking with the family’s permission.

I got nowhere. No one I interviewed at cancer organizations had heard of a policy change — nor had a billing staffer at St. Francis Hospital who checked Diane’s file.

More frustrating, none of the helpers at 1-800-MEDICARE whom I phoned repeatedly could tell me anything about the MRI without the specific CPT code.

Me: The doctor did not give the patient the code. But I’ve described the procedure. Why can’t you tell me the code? Is it a secret?

Helper: No, the codes are not secret. But I’m not allowed to tell you a code. You need to get it from the doctor.

Me: What can Diane do?

Helper: Tell her doctor to call the Medicare Provider Helpline. People there can tell the doctor whether Medicare is likely to cover her MRI.

Me: You’re telling me there’s a Medicare phone line with the answers, but only doctors can call it? Does that sound fair to you?

Helper: Can I help you with anything else?

Catch 22. No CPT code. No answers. No MRI for Diane.

[Dr. Sugardaddy]

It's turtles all the way down.

Yup, pretty much (I can't believe I missed that thread. I've got to pay more attention).

And yes, LawBeef is correct that, if used as intended, the ICD10 coding system could provide us a wealth of potential research information. I'm skeptical, though, that it will produce information that we can't find out somewhere else. To build on my "bang your head in the kitchen" example, we already know that most accidents happen in or near the home, and we know that the kitchen is the most potentially dangerous room in the house (assuming you don't consider the garage to be "in the house;" if so, then it's a dead heat between the two).

When you've got a medical provider who must see 25+ patients per day to make ends meet under the current reimbursement system--which, to be fair, shows signs of potentially changing--I would argue that there are more efficient, cost-effective sources of epidemiological data than an overly complex coding system driven by overworked medical providers. A lot of providers will try to argue that they're not coders, but they have to know their "bread and butter" codes by heart to make good use of their limited time with each patient. ICD10 simply promises to make that process more complex.

[Smoove_B]

and we know that the kitchen is the most potentially dangerous room in the house

What data are you looking at? Mine suggests (and has for a long time) that the most dangerous room in your home is your bathroom....

[Dr. Sugardaddy]

At the mercy of Medicare's codes

The health care industry speaks in code.

[content snipped]

Catch 22. No CPT code. No answers. No MRI for Diane.

It's aggravating, to be sure. I'd chalk that up to lousy customer service skills rather than a nefarious conspiracy, however. I'd have to check to be sure, but there may be over a dozen MRI CPT codes that apply in that situation. Even if the rep went over each and every one of them, few (not zero, but few) patients would know whether it was "MRI with contrast" or "MRI without contrast", etc. In our current system--for better or worse--the ordering provider is the one who has the best knowledge of his or her intent. Implying or inferring that CPT codes are secrets that only providers know is just a crappy way of describing that situation.

Truthfully, I'm appalled at how un-transparent the health-care system in the U.S. continues to get away with being--and I'm a part of that very same system. Almost any other industry that kept pricing and practice performance information as secret as health care does would have gone out of business a long time ago. Hopefully, we'll see this change in a few years.

[Dr. Sugardaddy]

and we know that the kitchen is the most potentially dangerous room in the house

What data are you looking at? Mine suggests (and has for a long time) that the most dangerous room in your home is your bathroom....

Oops...you're right. It is the bathroom. Even the NY Times knew that 2 years ago. The kitchen is the danger spot for abused spouses during arguments (unless your house has a gun room). Stupid limited brain, getting facts mixed up!

Thanks, Smoove.

[Smoove_B]

No problem. I thought I missed something and I needed to rush to update slides.

[Kraken]

Truthfully, I'm appalled at how un-transparent the health-care system in the U.S. continues to get away with being--and I'm a part of that very same system. Almost any other industry to kept pricing and practice performance information as secret as health care does would have gone out of business a long time ago. Hopefully, we'll see this change in a few years.

Yeah, that was the point of the linked column. The patient has no way of knowing what a procedure will cost or how much of that cost will be covered. She can't afford to hope for the best, so she can't have the procedure.

I had a similar experience with a colonoscopy some years ago. My insurance company told me it would be 100% covered. They didn't tell me that I'd be responsible for the cost if any polyps were found and removed. It cost me $850 to find out that preventive care is covered but diagnostic is not. Now I'm supposed to go back for colonoscopies every couple of years? Fat chance.

BTW, welcome back Dr. S. Haven't seen you around for awhile.

[Dr. Sugardaddy]

BTW, welcome back Dr. S. Haven't seen you around for awhile.

Aww, thanks! I've been lurking, but not posting so much. It's nice to be remembered. I guess that's an advantage of sigging someone.

I waffle on this ICD10 thing. On the one hand, it seems dreadfully complicated...even in a system that sometimes seems to pride itself on being dreadfully complicated. On the other hand, much of the rest of the world has been using it for a while now, so part of me thinks we're being a bit wimpy in whining about it so much.

[Jeff V]

For some reason this thread makes me want to play Advanced Squad Leader.

I have my ASL rulebook listed for sale on Fleabay. You should buy it!

[Isgrimnur]

Roll out!

Beginning Thursday, doctors, U S Hospitals and other health care providers will start using internationally developed standards (ICD-10 codes) to invoice private insurers and government programs in the $2.9 trillion health care system of the nation. The codes cover all those that could be even distantly possible, a parrot bite to a jet engine sucking you in.

v97.33 - "Sucked into jet engine"

Already, doctors have started mocking their diagnostic list, picking what appears the most arcane and absurd like Z63.41 “Problems in relationships with in-laws” or V91.07XA “Burn due to water Skis on fire.” Though this could be a joke for some readers, for doctors, insurers and all those whose payments are linked to the codes, the complex change are dead serious.

v91.07 - "Burn due to water-skis on fire"

The debut of the new codes has already been delayed twice by administration officials. However, they now say that the new codes will help in identifying efficient ways to manage all type of conditions from injuries from roller skating to heart diseases.

[Scuzz]

My wife started coding work that had both Icd-9 and Icd-10 codes on it yesterday. Sadly today is her last day of work as her current employer is dropping the client she works for (the guy is shrinking his business in preparation for retirement).

She took the Icd-10 test and failed by 5 points. Sadly those 5 points are the difference between her being a highly sought after commodity and just another coder looking for a job.

[LawBeefaroni]

She took the Icd-10 test and failed by 5 points. Sadly those 5 points are the difference between her being a highly sought after commodity and just another coder looking for a job.

Ouch. Can she re-take it?

Either way there's a pretty good market out there, even for "JAFCs". If errors and payment delays start piling up, as is expected, I'm sure the market will only get better.

[Scuzz]

She took the Icd-10 test and failed by 5 points. Sadly those 5 points are the difference between her being a highly sought after commodity and just another coder looking for a job.

Ouch. Can she re-take it?

Either way there's a pretty good market out there, even for "JAFCs". If errors and payment delays start piling up, as is expected, I'm sure the market will only get better.

She plans on re-taking it. She interviewed for 2 jobs this week, with one looking pretty good. There are a lot of jobs out there but she lacks some of the experience they are seeking. While she has coded for 5 years her boss kept her mainly in the "easy" stuff because there was nobody else in the office to do it. So she got some training on other work but not enough.

She has a friend who runs coding for a Bay Area hospital and might get work out of that.

[Isgrimnur]

W61.32XA - Struck by chicken, initial encounter

[Isgrimnur]

Isn't the rest of the world moving to ICD11 in 2015?

WHO

The 11th Revision of the International Classification of Diseases (ICD-11) is due by 2018!