Under the ICD-10 — the 10th edition of the International Classification of Diseases — health officials in the United States hope to track quality of care more accurately and to identify disease outbreaks before they happen. Doctors expect a nightmare.
Rollouts of the Affordable Care Act in the United States haven't really gone very well.
When the website for the health insurance exchange, healthcare.gov, went live in October 2013, it was several weeks before consumers could shop for health insurance without tearing their hair out. A year before that, a new standard form for electronic submission of insurance claims had slowed down payments to doctors so much that many of them could not meet payroll.
On October 1, 2015, another innovation required by the Affordable Care of Act will wreak havoc in doctor's offices all over the United States. This new system is the ICD-10, the new 110th edition of the International Classification of Diseases.
What's The Problem With The ICD-10?
The ICD-10 is a collection of 68,000 codes that explain what a doctor has done during an encounter with a patient. Each of the 68,000 codes corresponds to a different payment amount under agreements with the various insurance companies that the doctor works with. The advent of the ICD-10 has some doctors hunkering down the way some people did 15 years ago in anticipation of Y2K.
The ICD-9 had 56,000 fewer codes than the ICD-10. For many years, medical coders and doctor's billing offices had become adept at reading doctor's notes and assigning treatment to one of just 12,000 codes, each described with a four- or five-digit number. Now coders and billing specialists have to master 56,000 new six-digit codes, many of them for services one does not typically encounter in a doctor visit. These include:
W55.41XA: Bitten by pig, initial encounter.
W61.62XD: Struck by duck, subsequent encounter, (The patient has been struck by a duck more than once.)
W55.29XA: Other contact with cow, subsequent encounter. (Since there are other codes for "kicked by cow" and "bitten by cow," this code refers to, uh, other injuries in interactions with cows that happen more than once).
V00.01XD: Pedestrian on foot injured in collision with roller-skater, subsequent encounter,. (The same roller skater has collided with the same patient more than once.)
W220.2XD: Walked into lamppost, subsequent encounter (which is to say, the patient had walked into a lamppost before).
W22.02XD: V95.43XS: Spacecraft collision injuring occupant, sequela. (This is a follow-up visit with a patient injured in a spacecraft accident.)
R46.1: Bizarre personal appearance. (Presumably Lady Gaga's doctor would get an additional payment if she arrived for a medical appointment in her meat dress.)
Absent from the ICD-10, however, is the ICD-9 code for "suicide by paintball gun."
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How Do American Doctors Feel About The New Diagnostic Codes?
A few doctors welcome the changes in the diagnostic codes, noting that they can now more precisely describe the care they give to patients. Other doctors simply decided to retire on October 1. Austin, Texas medical practice Austin Internal Medicine Associates closed its doors on September 4 in the face of increasing administration burdens, one of which was ICD-10. "Of all the hassle factors, it's down the list a ways," R. Scott Ream, MD, told Texas Medicine, "but it's definitely why we chose [September 4, 2015]."
How ICD-10 May Affect You
Much of the American medical establishment reports that it is ready for the changes in billing codes:
- 100 percent of health insurance companies report that they are ready for billing code changes.
- 90 percent of hospitals updated their coding systems. This is despite the fact that the number of billing codes for hospitals has increased from 4,000 to 87,000.
- 10 percent of doctors surveyed report they are "confident" that they are ready for ICD-10.
Many doctors are concerned that claims will not be filed properly and they will not receive payment if they do not use the new codes, or they do not use them properly. There are over 100 different codes just for gout. There are 200 different codes for diabetes. There are even 30 codes for injuries caused by terrorism.
Doctors and clinics are seeking lines of credit for three to six months while they are adjusting to the new system. Nearly all of them, of course, will continue to provide services to their patients.
The main way patients will experience difficulties due to the new medical coding system is delays in insurance preapprovals. In the United States, visits to a primary care provider never require preapproval by the insurance company. HMO plans, however, require that the primary care provider get preapproval to refer a patient to a specialist. Preapproval may also be required for certain medications and for many procedures. Physical therapy of all kinds and home health care also require preapproval under most insurance plans.
What this means is that if your doctor wants to send you to a physical therapist when you break a finger, your preapproval may be denied if the doctor fails to use the code that tells the insurance company which finger is broken or in which hand.
In the case of cancer treatment, failure to use the right code might be far more serious. Preapproval is required for chemotherapy. There are 70 ICD-10 codes for various forms of Hodgkin's lymphoma. All of these codes with "C81." To get payment for the office visit, to qualify for incentive programs, and to get the patient chemotherapy treatment, many companies will require doctors to use the exact treatment code. This isn't necessarily straightforward.
If the doctor makes a diagnosis of nodular sclerosis classical Hodgkin's lymphoma, for instance, he or she may code the cancer as found in intrathoracic lymph nodes (C81.12) or intra-abdominal lymph nodes (C81.13) when in fact the cancer in the lymph nodes of the inguinal region and lower limbs (C81.15). Getting the last digit wrong may doom the claim.
The federal government promises to be lenient with doctors for the first year, making payments if the codes are at least logical and in the right treatment group.
In the case of the Hodgkin's lymphoma case above, Medicare and Medicaid will probably make payments if the doctor at least enters "C81." However, private insurance companies are not required to be as lenient. Especially if you are insured by an HMO, expect substantial delays in getting tests, procedures, and medications approved for the next year. If you face multiple health conditions for which these delays can cause critical problems, consider signing up with a healthcare provider that does its own insurance claims, such as the Kaiser-Permanente system in California or the Baylor Scott and White plan in Texas.
Sources & Links
- Robert Lowes. ICD-10: Countdown to a Meltdown, or a Yawn? Medscape Medical News. 24 September 2015.
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