The October Surprise that Could Cripple the Practice of Medicine

By Brian C Joondeph

You won’t read about the International Classification of Disease (ICD) on TMZ or hear it discussed on The View, but it has the potential to be an unpleasant October surprise in the health care world.  It is a list of codes that physicians and hospitals use when billing insurance companies.  These codes cover all manner of medical diagnoses for diseases, conditions, and injuries.

The first version of the ICD appeared in 1946, with periodic revisions since.  Six months from now, on October 1, the latest version, the ICD-10, will be implemented in the U.S.  We are late to the party, with other countries having implemented this over the past 15 years.  The ICD-10 has already been delayed for a year, but the administration promises no further delays.

The ICD-10 is not the fault of ObamaCare, nor is it Bush’s fault.  The classification preceded even Bill Clinton.  So this is not a partisan issue.  Instead, it is an issue of complexity, arriving in the wake of the largest health care overhaul in history, with its attendant chaos and confusion.

The current version, the ICD-9, uses a 4- or 5-digit number to code for a particular disease, such as 540.9 for appendicitis.  The ICD-10 will have up to 7 alphanumeric characters to specify a condition, such as S52.521A for “torus fracture of lower end of right radius, initial encounter for closed fracture.”  And there are now over five times as many codes for doctors and hospitals to choose from.

But isn’t specificity better?  Sure it is.  Big data is the new frontier in medical research, making sense of the huge amount of generated health care data.  But can this go too far?

In an effort to push specificity to the limit, some ICD-10 codes have gotten silly.  Codes exist for being hurt at the opera (Y92253), walking into a lamppost (Y92253), walking into a second lamppost (W2202XD), getting sucked into a jet engine (V97.33XD), and being burned due to water skis on fire (V91.07XD).

But this is not the Achilles heel of the ICD-10.

First, medical practices and hospitals must know and have all of these 68 thousand codes readily available to add to the medical record in order to bill correctly and hope to be paid.  One more distraction for physicians, aside from all of the daily distractions of electronic records.  When physicians pay more attention to their computer screen or tablet than to the patient, guess who suffers.  This is the reason why texting and driving is illegal.

Second, electronic medical records (EMR) must be able to incorporate these codes into the exam or procedure report.  Are all EMR vendors up to speed on these codes?  Will their system upgrades work as advertised?  Or will they work as well as the Healthcare.gov website? 

 And if the codes don’t work, physicians and their practices don’t get paid.  Yet landlords, employees, and utility companies still want to be paid.

Third, will the insurance companies recognize each of these new 68 thousand codes, correctly match them to billed procedures, and promptly pay the providers?  If I treat a patient with macular degeneration with a monthly dose of a $2,000 drug, I now bill a single code, which insures that I will be paid.  Under the ICD-10, there will be 20 codes, specifying which eye(s) and severity, that allow payment.  Will every insurance company have each of these codes in its computers?  Will it recognize each code?  Remember that these are the same insurance companies that don’t even know who has actually paid their insurance premiums.

The American Medical Association announced this week that ICD-10 implementation will cost three times as much as originally estimated.  The  “costs of training, vendor and software upgrades, testing and payment disruption” could be $225,000 for a small medical practice and over $8 million for a large practice.  How do medical practices of marginal profitability absorb these costs?  With physician reimbursement rates set to grow at only half a percent per year over the next five years, far below the true rate of inflation of close to 10 percent, the financial writing is on the wall. This will accelerate the demise of private practice, already underway due to ObamaCare.  Come October 1, “The doctor is in” may be a phrase of historical interest only.

Brian C Joondeph, M.D., MPS, a Denver-based physician, is an advocate of smaller, more efficient government.  Twitter @retinaldoctor.