Does ICD-10 Delay Create an Easy Opportunity for Coding Improvement?

Implementation of ICD-10s has been delayed “indefinitely.”   Rather than opine on whether that’s a good thing or a bad thing, I will note that it creates an opportunity for a simple but powerful improvement in the value of the coding.

Caveat:  I am not a coding expert (I don’t even play one on TV) so there might be something wrong with this idea.  The specific reason for the post is to find out whether there is some reason this can’t be done, given the value of doing it.  (I am so unfamiliar with coding that it is possible this is already being done and I’m the last guy to find out about it, in which case perhaps John and Matthew would be kind enough to remove it.)

Quite simply, how about adding an optional  “R” for “rule-out” after the codes?  For instance, today if a patient gets tested for diabetes and it turns out that he HAS diabetes, he gets coded “250” in the ICD-9s.   Whereas if it turns out the patient does NOT have diabetes, he still gets coded “250.”   My proposal would code that (in ICD-9s) 250R.

By contrast, giving two opposite diagnoses the same code creates a cascading set of problems, in outcomes measurement, risk scoring, registries, disease management, reimbursement, and predictive modeling, problems that will be exacerbated as risk shifts down to the provider level and payors move to outcomes-based reimbursement.

Adding an “R” to the latter seems like an easy, intuitive fix that would not set back the ICD-10 adoption process any longer than it already is.  Tough to be set back longer than “indefinitely.”

Thoughts from THCB nation are appreciated.

Al Lewis, widely credited with inventing disease management, is author of the forthcoming Why Nobody Believes the Numbers (John Wiley & Sons, June 2012), the introduction to which may now be downloaded gratis from www.dismgmt.com . He also runs the popular course and certification program for Critical Outcomes Report Analysis and was named the “leading authority on care management outcomes measurement” by the 9th Annual Report on the Disease Management and Wellness Industries  (Health Industries Research Co., 2010).

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4 replies »

  1. If you aren;t test ing me for diabetes or hypertension until i have symptoms, i guess I’m glad you’re not my doctor!

  2. Clearly, you are not a coder as you have stated. As Dr. Mike alluded to your method would narrow the specificity rather than expanding it (the whole point of ICD-10). The problem does not really lie in ICD-10 itself as most of the rest of the world has been using it for years. The problem rather is the U.S. links coding to reimbursement and Medicare being the largest payer in the country and federally run changes come at a snail’s pace as well as the IT impact these changes have as Margalit noted.
    Perhaps you should remember that the original reason for coding in the first place was to collect information on disease occurring in our communities to better care for patients and it is still used for that purpose.
    In you diabetes example, you should first know that 250 is not the ICD-9 code. 250 is the category and is further expanded by adding 4th and 5th digits for a total of 40 different codes for diabetes mellitus. By using 250 you wouldn’t know what type of DM the patient had, if it was controlled or not, or if there were complications related to the DM or not. Also, as Dr. Mike pointed out if this patient turns out not to have DM (by adding R), there is no indication as to why this patient is being tested for DM in the first place.
    From a financial perspective, insurance companies are not going to pay for any old test for no known reason. Granted a DM test is pretty straight forward and inexpensive but how about the patient that comes in and gets an MRI of the hip for a possible fracture? If it turns out not to fractured you are saying adding an R to a fracture code. There is no documented justification for such a test in your scenario. There should be a code for an injury or pain in lieu of your idea otherwise there is no accountability that someone just had an expensive MRI because they thought their hip may be broken.
    From a clinical perspective, your proposal offers no capture of what is really happening in the community, just what individuals don’t have which isn’t very helpful to advance medicine.

  3. From a purely technical perspective, adding a letter to the ICD-9 will require all sorts of changes to the claim form, the EDI and to the programming logic in EMRs and claim processing software and scrubbers of all types and shapes. It will cost a lot of money.

    I do appreciate the “cascading set of problems” this may cause (unless you code the symptoms as Dr. Mike noted, and most people do), but I am not seeing patient care in your list, Al.

  4. The preferred way is to code the symptom or finding, i.e. in the case of possible diabetes, to code for hyperglycemia or for polyuria. Coding for rule out doesn’t really add much – for example swelling of the legs could be blood clots, dependent edema, or CHF just to name a few, and coding “rule out CHF” wouldn’t be as accurate as just “Edema”