The Devil is In The Details
The ICD-10 code, created in 1983, was finally implemented here in the US on October 1st,2015 and it is all about the details. The devil is in the details as they say and you can believe that the devil is in the ICD-10 code. A recent article goes to the heart of the problems. Healthcare once about people and healing, is now about coding and quantifying.
Quantifiers and coders are looking at healthcare essentially from the outside and healthcare professionals are looking from the inside. Quantifiers and coders want data for what you ask, for everything from billing to monitoring results of treatment, quality of care, to identifying outbreaks of disease, causes of death and community health needs etc., etc., etc..
I am reminded of a short essay by C.S lewis called Meditations in a Toolshed
I was standing today in the dark toolshed. The sun was shining outside and through the crack at the top of the door there came a sunbeam. From where I stood that beam of light, with the specks of dust floating in it, was the most striking thing in the place. Everything else was almost pitch-black. I was seeing the beam, not seeing things by it.
Then I moved, so that the beam fell on my eyes. Instantly the whole previous picture vanished. I saw no toolshed, and (above all) no beam. Instead I saw, framed in the irregular cranny at the top of the door, green leaves moving on the branches of a tree outside and beyond that, 90 odd million miles away, the sun. Looking along the beam, and looking at the beam are very different experiences.
But this is only a very simple example of the difference between looking at and looking along.
C.S Lewis argues that ,”One must look both along and at everything. In particular cases we shall find reason for regarding the one or the other vision as inferior.”
Forcing healthcare workers to look at healthcare in the manner of the ICD-10 code results in an endless preoccupation with data entry and proper quantification. The living experience of looking along the healthcare beam of light is wreaked in the process. Minds become fixated on something other than care, practicing the art of medicine, and healing. No wonder indeed that Doctors and other healthcare workers are burnt out. The brave new world of healthcare will end up being just that, healthcare for the brave.
Please read this excellent article by Shirie Leng, MD
ICD-10: No wonder why doctors are burnt out
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Yes, friends, after two years of delays, ICD-10 is coming to a doctor near you on October 1st. Mark your calendars. To review:
1. ICD-10 stands for the International Classification of Diseases, version 10. The ICD is, according to the World Health Organization, (www.who.int) which publishes and maintains it, “the standard diagnostic tool for epidemiology, health management, and clinical purposes. It is used to monitor the incidence and prevalence of diseases, providing a picture of the general health situation of countries.” In the U.S., the ICD has been adapted for billing.
2. Work on ICD-10 started in 1983, but here, the U.S. Department of Health and Human Services still used ICD-9 (with modifications called ICD-9-CM) until 2013, after which it was delayed twice by Congress.
3. The ICD coding system attaches a number for every disease or trauma known to mankind. For example, if you have a broken forearm you have an ICD-9 base code of 813. If it is a closed fracture (the skin was not broken), you’re an 813.0. If it is the lower end of the arm, you’re an 813.40. If your skin was also broken, and the bone poked through, you’re at an 813.50. If you only broke your radius, but the skin was broken, you’re an 813.52. And so on.
4. There are other codes you need too. Your broken arm will need to be splinted, which requires a current procedural terminology (CPT) code or an ICD-10-PCS code, depending on if you are going home from the ER or have been admitted to the hospital. The Healthcare Common Procedure Coding System (HCPCS), which wrote the CPT codes, also has level II CPT codes for ambulance services, crutches, etc. There are also “E-codes” to record external causes of injury (vs. breaking your own arm, I guess). And there are V codes for supplementary classification of other problems you might have that relate. So if you broke your arm while pregnant, you might be an 813.0V22. I think.
5. A whole industry has been created around these codes. Hospitals hire professional coders whose job it is to read through patient records and determine the correct ICD codes to submit to Medicare. Hospitals also hire computer programmers or computer software companies to link hospital data systems to these codes.
So, why do we need new codes? What’s wrong with the old ones? About 100,000 things. That’s the number of new ICD codes that have been created. These new codes require much more specific information. Now your broken arm is classified according the type (open or closed), pattern (spiral or oblique etc.), etiology (how it happened), healing status (in subsequent visits), localization (head, neck, distal, proximal) displacement, classification (Colles vs. Salter-Harris etc.) and laterality (right or left). Because breaking your left arm is pretty cheap but breaking the right will cost you, I guess.
In ICD-10, your broken arm makes you an S52. Which is, of course, way cooler. If you broke the distal (far) end of your radius you are an 813.4 in ICD-9 but in ICD-10 you could an S52.51 or S52.52 depending on which arm. You could also be an S52.516 or S52.519 or S53.517, depending on alignment and classification. If this is the first time you are being seen for your broken arm, you might be an S52.511A.
The purpose of all this, say the experts, is more specific data collection. According to the New York Times:
The new codes will … make it easier for insurers and federal officials to measure the results of treatment and the quality of care — factors increasingly used in deciding how much to pay doctors and hospitals. Public health officials say the new codes will help them identify outbreaks of disease, causes of death and community health needs. Researchers say the data will help them evaluate new treatments and procedures.
I would also add that coding companies and health care data companies will also benefit greatly.
OK, you say, but the actual dollar reimbursement amounts won’t change, so who cares? Let the coders take care of it. Doctors care. A lot. Who do you think is recording all this extra data? Doctors. The amount of information about the patient that the doctor knows doesn’t always change, but how much of it has to be documented does. It is all about documentation. If that coder doesn’t see it written down somewhere, that coder will call the doctor, or code wrong. If they code wrong, the doctor doesn’t get paid, and the bill goes to you, the patient. There is no short-term benefit for the doctor, but the documentation required goes up significantly. ICD-10 gathers more data. Doctors do the gathering and the typing. Which is what we went to medical school for.