As most of us know, the government has mandated that when medical bills are submitted to insurance companies, Medicare and Medicaid, they must put certain diagnostic codes on the claim. That way, they can know why you saw the doctor. They can also decide whether or not they will pay for your care. Isn’t it great that there are so many people looking out for you?
There is a lot of consternation and anxiety in the medical community because the government has decided to “upgrade” the coding system. They are compelling any doctor, hospital, or any other medical provider or supplier to stop using the present imperfect system of coding, ICD9 (International Classification of Diseases, Ninth Version) and convert to ICD10. Newer is better, right? Most people don’t think so. Let me explain why.
The ICD9 system has always been a pain. It has far too many codes that are not needed, and several that doctors would like to see do not exist. If a doctor, or in many cases, a billing clerk/coder does not put in a code accepted by insurance, they will not get paid for treating the patient. Sometimes, they have to make their best guess, aka “fudge it.” Often honest mistakes are made. If an audit is performed and some of these best guesses or honest mistakes are found by Medicare, not only can a doctor be compelled to pay back the money with interest, but he/she could be thrown in jail. The government used to look at this as a civil violation. Now it is increasingly viewed as a criminal one. (“Hey bub, what are ya in for?” “I billed someone for chest pains, but they had hearburn.”)
Knowing this, you would think a new and improved system would be better for doctors and patients. The stated purpose for going to the new system is 1) to make coding more efficient and save money, and 2) to improve data mining for population health purposes. I want to address both arguments.
First, the new system will not save money. Doctors and hospitals are not ready to implement the changes required for the new system. It has been pushed back a few times already. The drop dead date for using the new system is approaching. I use “drop dead” literally, because many small practices will not survive the change. The new system is far more complicated that the old one. The ICD9 system has about 15,000 codes in it. The ICD10 has about 68,000. They did not just add codes to the old system. They replaced all of them in a different format. It requires a whole new billing system. In the world of electronic medical records and billing, that means a lot of money going for software upgrades that could have gone to something else to improve the practice. The cost of upgrading billing and software systems is immense. It may cost tens of thousands of dollars per provider to change their systems. We are not sure how this is helping to save anyone any money (except maybe the insurance companies who won’t have to pay the bills). Many small, independent practices are barely surviving financially already. This change may bankrupt them.
Second, why should the insurance companies and government have so much data on you in the first place? Shouldn’t the reason for you seeing your doctor be between you and your doctor? I don’t think it is an insurance company minion’s, or government bureaucrat’s business that you saw your doctor for a wart, hemorrhoid, or even a cold for that matter. They call it personal health information for a reason. It is personal! Why would we want to make it that much easier for these third parties who are not directly involved in your care to know so much about you?
I will add a third argument for why we should not use the new system. It is just plain silly. There are a lot of codes in the new system that are hard to take seriously. Several people have pointed out some of the most absurd. I will do so as well.
The list and commentaries below comes from the article, “The 16 most absurd ICD-10 codes” by Katie Bo Williams, published in The Heathcare Dive Blog on July 15, 2014:
16. V97.33XD: Sucked into jet engine, subsequent encounter.
Sucked into a jet engine, survived, then sucked in again? First of all, that really, really sucks. Second of all, this patient is obviously Wolverine, and should be detained for imaging and posterity. (Technically, this means “subsequent encounter with a physician” not “subsequent encounter with a jet engine,” but that’s less dramatic.)
15. W51.XXXA: Accidental striking against or bumped into by another person, sequela.
The “sequela” here implies the kind of human bumper cars that can only happen at a music festival, the subway or possibly an active combat zone. Potentially fatal for agoraphobics. Recommend handling with care.
14. V00.01XD: Pedestrian on foot injured in collision with roller-skater, subsequent encounter.
First, are roller skates even still a thing anymore? I mean, other than how one knows spring has sprung in Central Park? Second, can you call a person on roller skates a pedestrian? Thirdly, if the answers to one and two are “yes,” then these things should be outlawed, because they are obviously dangerous.
13. Y93.D: Activities involved arts and handcrafts.
Camp is a dangerous thing. Hot glue guns and knitting needles definitely wouldn’t be allowed on a plane, yet we habitually allow 7-year-olds to play with them. This is a public health crisis that needs to be addressed.
12.Z99.89: Dependence on enabling machines and devices, not elsewhere classified.
There’s a reason they call it the Crackberry. This is an obsolete joke, but there just isn’t an iPhone pun that can compete with “crackberry.”
11. Y92.146: Swimming-pool of prison as the place of occurrence of the external cause.
There is also a code for “day spa of prison as the place of occurrence.”
10. S10.87XA: Other superficial bite of other specified part of neck, initial encounter.
Alright, people. Let’s call a spade a spade. “Other superficial bite of other specified part of the neck?” This is a hickey. Admit it. Although why anyone would be admitted for that remains a mystery.
9. W55.41XA: Bitten by pig, initial encounter .
First, be sure that the patient is restrained from doing whatever he or she may have done to provoke the pig in the first place. Security should be placed on alert. Also, what was this person doing in a farm setting in the first place? Pigs are not pets.
8. W61.62XD: Struck by duck, subsequent encounter.
Maladies that rhyme should be given immediately priority in the ER. Ducks, like most water fowl, are mean-spirited animals and this case should be treated with the utmost urgency as it is likely to be a serious injury.
7. Z63.1: Problems in relationship with in-laws.
6. W220.2XD: Walked into lamppost, subsequent encounter.
No. No. People. You only get to do this once. ONCE. If a patient is going around whacking into lampposts regularly, there is a deeper problem here, and he should be referred to psych immediately.
5. Y93.D: V91.07XD: Burn due to water-skis on fire, subsequent encounter .
How does this happen? Are water skis even flammable?
4. W55.29XA: Other contact with cow, subsequent encounter.
“Other contact with cow.” OTHER CONTACT WITH COW? There are codes for “bitten by cow” and “kicked by cow.” What else is there?! What, precisely, is the contact with the cow that has necessitated a hospital visit?!
3. W22.02XD: V95.43XS: Spacecraft collision injuring occupant, sequela.
The existence of this type of code does not engender trust in the National Aeronautics and Space Administration. Shouldn’t they have more control over their spacecraft than that? Or are they just careening around in the ether, pinging into one another and injuring occupants/astronauts?
2. W61.12XA: Struck by macaw, initial encounter.
Macaws are endangered—some are extinct in the wild—so if a patient has been struck by a macaw, chances are, it was the patient’s fault. Consider calling the SPCA and/or the police. The macaw needs to be found and treated immediately.
1. R46.1: Bizarre personal appearance.
LADY GAGA, IS THAT YOU? WE LOVE YOUR MEAT SUIT.
But seriously, who gets to decide what constitutes “bizarre personal appearance”? Let the people do what they want!
I just have to ask if there is an ICD10 code for physician stress and anxiety caused by dealing with idiotic bureaucracy and coding systems, subsequent encounter?? Answer: probably.
I want to point out to people that if you are contracting directly with your doctor and not using third party insurance to pay for it, like in a Direct Primary Care practice, none of the above applies. You can keep your hickeys, macaw bites, and hickeys subsequent to macaw bites between you and your doctor!
Michael A. Ciampi, M.D.