There’s A Code For That: Doctors Brace For 155,000 Choices

Suppose, in a comical sequence of indignities, you are pecked by a goose, bitten by a crocodile, crushed by a human stampede at an opera house, injured in a fall from your motorized scooter and — finally and irrevocably — sucked into a jet engine and spit out the other end.

Soon, your hospital will have a code for that.

The U.S. Centers for Medicare and Medicaid is set to enforce the implementation of a new medical coding system called ICD-10 (meaning, the 10th version of the International Statistical Classification of Diseases and Related Health Problems). Hospitals and insurers are supposed to be using the new diagnosis coding system starting Oct. 1.

The ICD directory is used worldwide, and the 10th version of it — which includes some 68,000 diagnosis codes and 87,000 more ancillary codes for various procedures and physical circumstances, 155,000 potential codes in all — is a substantial overhaul to ICD-9, which was developed in 1975 and has but 18,000 code entries.

The directory is one of the most important resources in all of health care, used by physicians, hospitals and insurers both for internal record-keeping, and for billing and reimbursement purposes. Recent versions of the ICD, whose lineage dates to the 1700s, are developed under the guidance of the World Health Organization.

Other industrialized countries have been using ICD-10 for years. In the United States, though, the issue is complex, with many moving parts.

Other countries have just one nationalized insurance payer, or state-owned hospitals, or both. And many doctors in other countries are paid pre-determined salaries.

Here, despite an ongoing push to reward hospitals and medical practices for good performance and population health, doctors and hospitals are still largely paid for every unit of service they provide — a system called “fee for service.”

And now, the guidebook used to identify those units and services is about to get much more specific.

The old code is “rather imperfect,” said Vivek Reddy, chief medical information officer for UPMC’s Health Services Division. “You don’t really get that kind of granular detail about what kind of disease you are treating.”

For example, while the ninth version of the directory offers some generic codes for heart disease, the new version drills down to the specific characteristics of the patient’s heart ailment — which blood vessels are blocked, whether the dysfunction is diastolic or systolic, and so on.

“The more specificity you have, the better you know” a patient, Dr. Reddy said. That has implications for the patient’s treatment and, over time, it paints a more vivid portrait of the nation’s health.

Physicians, though, argue that the portrait is far too vivid. Why does it matter for billing or patient-care purposes whether an injury occurred at a supermarket, a swamp, a synagogue, a squash court or a steeple-chasing course? All five are options in the ICD-10.

“Most physicians are dreading its implementation,” said John Krah, executive director of the Allegheny County Medical Society, the professional organization of local physicians.

“Many have prepared for it, but the consensus is that it is going to be unnecessarily complex and costly to implement for physicians, facilities and the nation … ICD-10 will do little to improve patient care, but is for statistical research purposes” for the federal government and insurance companies.

Apart from the bureaucratic headache, physicians are worried about financial harm. In a recent round of testing conducted by CMS, nearly 20 percent of test claims submitted via the new ICD-10 system were rejected by Medicare because of errors made by the doctors and clinical assistants submitting the claims.

If 1 in 5 claims are initially rejected by Medicare in the testing round, what might that mean for cash flow come Oct. 1?

That’s why doctors wouldn’t mind a delay in implementation — something that’s happened twice already, thanks in part to sustained pressure from medical groups. Most recently, ICD-10 was supposed to take effect Oct. 1, 2014, but was postponed last spring by Congress. The original go-live date was Oct. 1, 2013.

Could implementation be delayed again?

In a February hearing of the health subcommittee of the U.S. House Energy and Commerce panel, most of those who testified said they wanted the coding system to be installed as scheduled. But physicians are holding out hope that the ICD-10 issue could get folded into another long-running Washington, D.C., health care drama.

Physicians are facing a 21 percent cut in Medicare payments, which would take effect March 31 unless Congress moves to avert. The proposed cut is linked to an equation built into a 1997 law that ties physicians’ Medicare payments to the national economy’s “sustainable growth rate”; that equation is built to periodically re-calibrate payments to physicians.

Each time those cuts are due, Congress approves a temporary end-around that keeps physician pay where it is. If Congress again approves a temporary fix, this would be the 18th consecutive patch. Doctors want the problem to be fixed permanently, not temporarily.

“It’s still being discussed,” said U.S. Rep. Keith Rothfus, R-Sewickley. “We need to have a permanent fix. Doctors need predictability.”

With the deadline a week away, doctors probably won’t get their wish for a permanent fix. But it’s possible that a consolation prize, in the form of another postponement of ICD-10 installation, could be folded into the Medicare payment patch.

“It’s clear to me that some staffers are trying to figure out a way to assuage the concerns of some in the physician community,” Ilisa Halpern Paul, president of the District Policy Group at Drinker Biddle & Reath, said this month to Modern Healthcare, an industry journal.

That outcome isn’t the preferred one for hospitals and insurers.

The “frustration right now rests with the delays,” said Donna L. Ramusivich, senior vice president at Monongahela Valley Hospital. “It is a significant cost to us each time the implementation date is moved back.

“We have been gearing up and spending funds training staff, purchasing reference materials and upgrading computer systems. The staff training — of which most of the knowledge is forgotten with each delay — creates non-productive work time and overtime costs.”

Insurers believe the coding will allow “health plans to more precisely determine claim reimbursement,” and improve detection of fraud and waste, said Highmark spokesman Aaron Billger.

Dr. Reddy of UPMC sympathizes with physicians. “We’ve all sort of grown accustomed to a certain code scheme,” he said. But “lack of specificity can be a barrier to treatment,” and ICD-10 is far more specific than its predecessor.

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