ICD-10 and the Apocalypse

Screen Shot 2015-09-28 at 9.42.44 AMOctober first is nearly upon us.  For many of us, this date has little significance beyond the promise of cooler weather, lovely autumn colors, and the invasion of neighborhoods with giant inflatable Halloween decorations.  While these decorations are fascinating to me, they do cause me to ponder the enormous gulf  between my taste and that of my neighbors.  I am not certain if this is meant to scare off potential alien invaders or simply to make them think we are not worth bothering with.

October 1, however, is a huge day to the medical community.  It is a day that will live in infamy.  It is the object of dread, of diaphoresis, of doom.  October 1 is ICD-10 day.  This view was further bolstered when I went to the CMS (Government Medicare) website, there was actually a doomsday countdown timer at the top of the page. Just looking at this makes me anxious.

For those still unaware, ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system.  This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible).  This change should be cause for great celebration, as  ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar.  Really.

But, as Abe Lincoln may have said, better the devil you know than the one you don’t.  We all got used to the stupidity of ICD-9, and, like the crazy neighbor who puts huge inflatables of the Santa Maria in their yard on Columbus day, we learned to tolerate its eccentricities.  It’s better than having an axe murderer or hospital administrator in that house.  Unfortunately, the folks over at ICD Inc. got overly zealous in their desire for completeness, increasing the number of codes from the 17,000 in ICD-9 to over 90,000 in ICD-10.  It’s as if that neighbor not only added the Nina and Pinta to their lawn, but also inflatable natives infected with smallpox along with a mural depicting the skyline of Columbus Ohio.  It seems a bit over the top.

Anyone paying attention to this subject knows of the ludicrous codes now available to the medical community (being bit by a duck while wearing a thong, being bit by a duck that is wearing a thong, being bit in the thong by a duck, being crushed by a giant inflatable while eating kale, etc), so I won’t go into those now.  These give health wonks hours of entertainment, for which we are all grateful.  But there is a much bigger, more serious set of problems brought about by the onslaught on the medical community by the ICD hoards.

Before I go into this, however, let me state that, because I no longer live in the insurance world (doing Direct Primary Care), I do not bear the brunt of this apocalypse.  Yes, we are inconvenienced by the need to submit ICD-10 codes for consults, labs, and procedures, but that is about the extent of it.  I was tempted to get snarky here and lord this fact under my suffering colleagues, but thought better of it.  While this may be a boon to the growth of alternative practice models like DPC, gloating over it seems cruel.  Having lived in the land of insurance and codes for 18 years, the prospect of converting over to ICD-10 even now gives me cold sweats.

There are two main problems with this conversion from 9 to 10.  The first problem is that, as I’ve written before, codes are the product produced by health care businesses.  Health care providers (doctors, hospitals, and the rest) are paid for producing problem (ICD) codes and matching them with procedure (CPT and E/M) codes.  This is the product they sell to their true customer: the third party payors.  Submission of the wrong codes has one main result: no payment.  Codes are the lifeblood that carry the money to medical providers, and so changing those codes threatens the financial viability of medical businesses, large and small.  Get this conversion wrong, and you don’t make enough money to stay in business.

Now, because there has been enough time and the with ubiquity of EMR systems centered on billing, the ironic heroes in this may be the EMR vendors.  This should minimize the overall damage to the financial survival of medical businesses.  Despite this fact, the conversion of codes strikes at the very heart of our health care business model.

The bigger issue here is the fact that, while they are the ones saddled with the expense of conversion and the ones facing the financial risk of not doing so, there is no obvious advantage to the doctors themselves to be making this transition.  ICD coding is a billing nomenclature that does not give any apparent benefit to patient care. Codes don’t help us make diagnoses, nor do they improve doctor-patient relations. In fact, it’s very likely that this transition will lessen the ever waning focus on the patient while providers are obsessing on getting the code that will get them paid.  The only positive most medical practitioners will see out of this conversion is getting rid of ICD-9.

Perhaps, like the 30 foot Santa riding a motorcycle which exploded in my neighbor’s lawn last December, my fears are overinflated.  The reality is that October 1 will come and go without the world caving in on the medical community.  But my fear is that this is one more way our system is alienating and frustrating its workforce.  This is, in my view, the more serious problem that will soon overtake all others.  It is possible to still love practicing medicine, even in the screwed up system we have.  But the number of doctors, nurses, and other providers who are reaching their limit is growing quickly, as witnessed by the number of phone calls and emails I am getting from doctors looking for an alternative.

Perhaps that’s a good thing, as the misery created by ICD-10 may drive the system toward a better model.  But I don’t imagine the ICD corporation and its minions are pushing this on us with this intent.  Someone somewhere thinks this makes sense.

Just like my neighbor who thought it made sense put a giant inflatable pregnant woman in front of their house for Labor Day.

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17 replies »

  1. This is an amusing article, but surely the author is aware that the ICD nomenclature is maintained by the World Health Organization, and NOT by some nameless business conglomerate.

  2. Hi Margalit – I appreciate your comments about cost burden on providers from Federal regulations, a burden in terms of dollars, time and peace of mind. I don’t think that shifting the cost to researchers is viable, however. If EHRs were more intelligent it would help, but you’re right…no one appears willing cough up the cash. I see this issue as a reflection of missteps by ONC, including a failing health IT standards selection process that, e.g., repeatedly ends up requiring the re-use of overly complex and costly standards, while failing to require better usability (ease of use, usefulness, efficiency, etc.). Regarding the desire to replace clinical expertise with IT, I believe we should instead focus on supplementing clinical experience and judgment with evolving empirical knowledge that takes into account lessons learned from the field, is truly useful at the bedside, and is not overly prescriptive.

  3. Interestingly, the first ICD-10 code (in ascending code order) is for Cholera (A000.0), which is appropriate since it is a disease of profuse diarrhea. To me that is symbolic of the code diarrhea of the ICD system. The last code in ICD-10 (Z998.0) is for “Dependence on other enabling machines and devices” – again quite apropo, in my opinion.

  4. Hi Dr. Beller, I understand and appreciate the importance of granularity for scientific research (and actuarial purposes). But it seems unfair that the research community and the other secondary beneficiaries are consistently eschewing the additional costs of improvement, and I think we reached the point where the delivery system is no longer capable of absorbing those costs without harming patients.

    ICD-10 is just the latest problem in this trend of putting research ahead of individual patient care, which started with the meaningful use data collection. There is something rather disturbing when we act as if research is the primary mission of medicine, with patient care moving down to a secondary subservient task.

    I agree that technology could be helpful here, but there is a cost there as well, and I am not seeing anybody stepping up to the plate and offering to pay for the development of intelligent administrative tools. All everybody seems to want to do is make technology that replaces clinical expertise…. but that’s another story for another day….

  5. I have mixed feelings about ICD-10. I contend that, in general, having fine granularity when classifying a patients’ problems is good for research. This is because such granularity enables more precise cohorts for associating (a) diagnostic groups, (b) treatments/procedures/prescriptions, and (c) outcomes. This then enables development of better clinical protocols, guidelines, and pathways.

    However, having unnecessary diagnostic codes that do not help grouping patients by problem type in a meaningful/useful way, or that even obscure meaningful groupings with excessive granularity, is not a good thing. As such, efforts should be made by the scientific community to reduce the numbers of ICD-10 codes down to where it improves the validity and reliability of clinical research. The codes found useful in determining the most efficient and effective treatment regimens for different patient types should also be the ones used for billing. This should be an evolving process with each subsequent ICD iteration becoming more streamlined and useful.

    The issue of extra burden on the clinician is real and I don’t have an easy solution. Margalit’s suggestion that the researchers translate clinicians’ free text diagnoses to the appropriate code is interesting, but it may add another level of imprecision through interpretation of the text. It would be good if EHR’s simplified the process using maps to ICD-9 and a rules base to help fill in the gaps. And it would be best if real effort is made to get rid of clinically useless codes through empirical science.

  6. Cynicism aside now, I completely agree with you Dr. Rob. There is something awfully important, being pulled out of medicine… It doesn’t show up on the scales used to “measure” and quantify everything, but it was there, and it is still there in places, although greatly diminished now…. The term soul comes to mind….

  7. Wow, Margalit, that was pretty cynical. I do understand that the “International” does relate to the WHO, but the damage is done where those benefitting the least are the ones with the highest cost. This does not serve well to improve the morale of physicians who are already feeling overwhelmed and dumped on by the system. I really think the physician discontent is overlooked in a way that will come back to cause much trouble in the future. It is severe. I was a doc who was planning on being the last one off of the sinking ship, not one who would lead the exodus. I love being a doctor. Those who remain are the ones capable of divorcing their feelings from this and just running a business. It’s really bad.

  8. The problem, of course is that the entire burden of this falls on the docs and medical staff of practices/hospitals/providers. We benefit the least and yet carry the burden and cost.

  9. Rob
    Seeing the ICD change only through the lens of billing sells short the possible upsides to docs. The research data dictionary becomes much larger now. The information we learn can benefit clinicians a great deal and in ways prior r to now we could not have estimated.

    The cynic in you might say garbage in, garbage out. However, it’s all we got–and I suspect our precision in trials will improve.


  10. The ICD corporation is actually the World Health Organization, which maintains these codes supposedly to improve research and such. Deciding to use ICDs for billing purposes is entirely our fault, and with the advent of “value based” whatever, these codes will most likely have even greater impact on physician/hospital revenues.

    My humble suggestion would be to go back to letting doctors describe medical problems in English, and let “researchers” and accountants digitize the language into codes for their own purposes (let them be the ones to hire certified coders). Having physicians code is simply how the above stakeholders dump some of their operational costs on doctors and patients too, because busier docs are effectively creating a financial penalty for patients (i.e. pay the same for less time).

    As to the effects of the October transition, I would venture a guess that at least some small independents will go bankrupt, while many others will come close enough to bankruptcy to be terrified into selling out. And this of course is precisely what our “leadership” wants to see happen. So, win-win….