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Sun, Dec 21, 2014

KESTNER: New diagnosis codes will impact how you receive healthcare

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Last week I disclosed that a completely new system of reporting diagnosis codes to insurance companies and government agencies will be put into place later this year.

To illustrate the impact of the change from existing code set (ICD-9) to the newer replacement (ICD-10) consider that the current list of diagnostic possibilities from which a physician or provider must choose is around 13,000 entries. That means when your doctor decides what is wrong with you he or she must choose one or several codes from this list. Each code describes a single distinct condition or disease.

In ICD-10, which goes into effect Oct. 1, 2014, the number of possible diagnosis codes expands to more than 68,000 entries. This is not a typo. You are correct if you quickly determined that the new code set has more than five times the number of possibly diagnoses than the current one does.

This change is expected to severely impact all types of healthcare practices throughout the country. In a report published by the American Medical Association it was estimated that the actual cost to make this transition for a healthcare office ranged from estimates of $56,000 to more than $226,000.

Since it is not likely that medical science will discover 55,000 more diseases between now and October it is obvious that something more than reporting diagnoses is involved with the change.

In part, the new set of codes is expanded to allow for reporting in greater detail about the current condition. For example, if you come into my office and have a condition of muscle spasms affecting the back, currently your chart would reflect that your diagnosis code is 728.85 which is simply “muscle spasm” that might be located anywhere or possibly 724.8 which is “other conditions of the back”.

Using the new codes your chart would indicate M62.830 which is specifically “muscle spasm of the back.” Regardless of the code used to report your diagnosis to your insurance company, I will still provide the same excellent level of care for you today as I will after Oct. 1, 2014.  Changing the codes does not affect the care you receive.

However, requiring a greater level of detail in reporting to a third party does increase costs and requires more time that is not translated into better patient care.

For example, imagine a busy office of a family practice specialist. Instead of relying on the current familiar set of diagnoses that have been used for decades, every family practice doctor will now be required to spend more time drilling down through the code set to find the best code to use to describe the patient’s diagnosis. When you consider that in a family practice the next patient may be anywhere from a newborn to an advanced senior citizen and the range of diagnoses may range from a wide array of accidental injuries to serious common or rare complications of hundreds of chronic illnesses, it is easy to envision how this change might take its toll on the doctor and staff.

In many offices the physician does not actually do the coding. A trained coder is responsible for that. But in order for the coder to select the right codes, the physician must spend more time in documentation to allow the coder to ensure accuracy.

This will require additional training on the part of the physician and coding staff.  This training is not required to improve your treatment. It is required to ensure that third parties such as insurance companies and government entities have more detailed data about you.

In some cases, such as when communicating between healthcare professionals, the data may be helpful in immediately communicating greater detail about a patient’s diagnosis. But it is important to note that the people demanding the change are from the government, not the providers.

Some physicians are upset not only about the additional cost and time that will be required to comply with the new code sets, but also about the fact that in a way they will be evaluated on an ongoing basis about how much money they are saving the insurance companies or the government.

In other words, as the insurance companies, state and federal governments watch the data come in, not only do they know more about you personally, they will know more about your doctor.
As an example, if your doctor is more thorough and orders more tests than average, he or she may face cuts in reimbursements. Doctors will begin having financial incentives to reduce the amount of testing that they order. In a way, this means that doctors will soon be paid by third party payers such as insurers based upon how much money they save the insurance company. This means a shift toward practicing medicine by statistics rather than based on individual patient needs.

This is much like the debate of national testing standards compelled upon teachers having the effect that teachers are tending to “teach to the test” rather than to the individual needs of their students.

There are certainly some benefits in the adaptation to ICD-10. But as with anything else imposed by the federal government there will be unintended consequences as well.

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March 23, 2014 at 1:33pm
Dr Kestner'a article provides an accurate portrayal of the challenges that upgrading to the new ICD-10 code set will mean to busy time-strapped providers, but he fails to emphasize the real reason for ICD-10 and it's importance for the improvement of our country's entire healthcare system.

The ICD9 code set is nearly 50 (Yes-50) years old and it does not reflect the current practice of modern medicine. The United States is the only (yes, the only) developed country that is still using this outmoded and obsolete code set. ICD10 has been around for over 20 years and iCD11 is currently in development. ICD9 does not provide visibility into very basic clinical information such as laterality, trimester, or whether the patient was being seen for an initial or subsequent encounter.

By using a modern code set to reflect the clinical specificity of patient care, everyone wins. ICD10 will serve as the underpinning of consistent "big data" to allow population health management and greater visibility into physician quality scores. Everyone will benefit from the access to better data as if will require everyone to "up their game." Of course providers aren't Hapoy about this as they may not want their quality scores made publicly available, but that train has left the station, and it's just a matter of time before all providers will be easily compared based on their quality scores. Think of Yelp for healthcare, based on a combination of publicly available data and patient satisfaction scores. Transparency and visibility into provider quality are an important part of improving our healthcare system.

There are many cost effective tools for providers to learn and implement ICD10 into their workflow. The concerns are not really about the code set at all, but about the increased documentation specificity required in order to assign the right code. If providers consistently provided this specificity in their clinical notes this would not be a major issue. But many of us have seen the limitations of provider documentation and poor handwriting.

It's time for our healthcare system to "Up its Game," and ICD-10 is the foundation of a robust health data infrastructure that will bring many benefits beyond more accurate billing and reimbursement.
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