Better diagnosis coding

AMA CEO asks House Speaker to halt ICD-10

2012-01-26T15:24:00.001-05:00

The CEO of the American Medical Association has asked House Speaker John Boehner to halt the switch to ICD-10-CM in a letter dated January 17, 2012.

Excerpts from the letter:

The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patient care, and will compete with other costly transitions associated with quality and health IT reporting programs.

The timing of the ICD-10 transition that is scheduled for October 1, 2013, could not be worse as
many physicians are currently spending significant time and resources implementing electronic health
records (EHRs) into their practices.

Physicians must significantly invest in health IT while Medicare payment rates are falling farther below the practice cost inflation each year because of the Medicare sustainable growth rate formula (SGR).

Stopping the implementation of ICD-10, and calling on appropriate stakeholders including physicians, hospitals, payers, national and state medical and informatics associations, to assess an appropriate replacement for ICD-9 will help to keep adoption of EHRs and physician participation in quality and health IT programs on track and reduce costly burdens on physician practices.

Our only question is, what took you so long, AMA?

We've been saying these things for a long time.

ICD-10 precursor delayed: Will ICD-10 be next?

2011-11-19T08:53:00.001-05:00

The Centers for Medicare and Medicaid Services (CMS) announced that it will delay enforcement of its rule that all covered entities under the Health Insurance Portability and Accountability Act (HIPAA) upgrade from the 4010 standard for claims transactions to the 5010 standard. CMS has said that it will not enforce the January 1, 2012 deadline, delaying such action now until March 31, 2012.

Now, for someone unfamiliar with the details of CMS, HIPAA, and how health insurance claims in the United States are handled, the preceding paragraph will make no sense. The rest of this paragraph is a primer. Those who understood the previous paragraph may skip to the next one. In the United States, to receive reimbursement for their services, healthcare providers such as hospitals and physicians must submit insurance claims on behalf of the insured, who waives her right to receive payment on the claim (and so the doctor/hospital receives payment of the claim directly without going through the insured party). Because nearly everyone over the age of 65 in the United States is insured by the federal government through CMS, and because nearly every doctor and hospital in the United States cares for patients ensured by CMS, CMS has broad leverage to force doctors and hospitals to change how they care for all patients by dictating how they care for CMS patients. And hence, just about every doctor and hospital in the United States is a "covered entity" under the HIPAA law. CMS has the authority under HIPAA to dictate how covered entities submit their insurance claims to CMS. It is a general rule that private insurance companies follow CMS, so they require providers to follow HIPAA claims transactions standards as well.

Now, the primary, HIPAA-mandated insurance claims standards are a family of standards that go under the broad heading of '4010'. CMS has mandated that covered entities upgrade to the 5010 family, in large part because it is necessary to implement 5010 before switching to ICD-10.

The delay to 5010 therefore puts the October 1, 2013 deadline for the ICD-10 switch at risk. And because October 1 represents the first day of the federal fiscal year, it will be difficult to manage anything other than a delay that is an integral number of years (October 1, 2014, 2015, etc.) in the switch to ICD-10.

This delay in the 5010 deadline and the AMA's decision to fight the switch to ICD-10 are just manifestations of the unrealistic expectations, and the policies based on them, that this blog has pointed out for three years.

Yes, stop the switch. Let's have an open and honest conversation about what our next-generation information infrastructure should be, and what diagnosis coding system can best support it.

American Medical Association: STOP THE SWITCH

2011-11-19T08:29:00.001-05:00

Well, for sure this post is well behind the news. The American Medical Association (AMA) House of Delegates on Tuesday voted to "to work vigorously to stop implementation" of ICD-10.

In their own words:

The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care," said Peter W. Carmel, M.D., AMA president. At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records into their practices. We will continue working to help physicians keep their focus where it should be – on their patients.

Naturally, the next question is what will the AMA will do to derail the ICD-10 train? Well, apparently it is still too soon to tell, but it is up to the AMA Board of Trustees to implement House of Delegates resolutions, in general. Per the chair of the Board, Dr. Robert Wah, limited resources also constrain what the AMA will be able to do to fight the switch.

The AMA is certain to endure harsh criticism for its stance. Already, some are already reacting to the AMA's decision by repeating the myths that (1) ICD-10 is advanced, (2) it will improve care for patients, (3) it will improve information management in support of #2, and (4) the U.S. is backwards because other nations have implemented ICD-10. We have shown on this blog that all these assertions are untrue.

On the contrary, the AMA is to be applauded for its courageous stance against ICD-10.

Thus, we offer to the AMA, as a modest resource, the documentation on this blog, over a multiple-year period, of the many reasons and truths about the switch, and why it will certainly not afford the benefits its proponents claim.

Latest call for ICD-10 switch repeats the myths

2011-10-11T13:35:00.013-04:00

Dr. Wendy Wittington, Chief Medical Information Office for Dallas-based Anthelio Healthcare Solutions, repeats several ICD-10 myths in her advocacy for the ICD-10 switch:

Myth #1: "...the switch is truly necessary"

We don't have to switch to ICD-10-CM. As we previously discussed here, there is an alternative approach, that is superior to ICD-10-CM.

Myth #2: ICD-10 is more modern

ICD-10 is still based on the same, antiquated, classification architecture as ICD-9-CM (see here, here, here, here, and here). So although it may reflect how medicine has evolved, it does not reflect informatics best practices. ICD-10-CM's underlying information architecture remains in the 1970s with ICD-9-CM medical terminology. The government is developing ICD-10-CM using a word processor!

Myth #3: ICD-10-CM will accurately translate what physicians do to payers.

Doctors don't recognize 318 kinds of diabetes mellitus (see here and here). Doctors don't use the terms "not otherwise specified" and "not elsewhere classified". Doctors don't speak in classifications, they speak in medical terminology. Doctors don't combine multiple patient characteristics into new diagnoses.

Myth #4: ICD-10-CM is necessary for evidence based medicine and comparative-effectiveness research.

As long as it's a classification and not a nomenclature, it will not be sufficient.

Myth #5: Silly codes do not get in the way.

See here for what a "silly code" is. They increase the cost, difficulty, and complexity of switching. Only necessary codes should be present. They will also inflate the number of search results a physician must process in an electronic medical record when looking for codes. For example, a search for "diabetes mellitus" will return 318 results!

Myth #6: Other countries have switched, therefore we're an embarrasment

Following the pack is not always a wise strategy. For many reasons listed on this blog, switching to something other than ICD-10-CM would be leading, not following. And certainly not embarrassing.

Myth #7: "...a lot of hospitals and healthcare providers have ignored it or put it on the backburner because they are too busy with meaningful use requirements"

Whoops! That one's not a myth. Meeting meaningful use requirements is probably a better expenditure of resources, and hospitals and physicians know it and appear to be acting accordingly.

Nearly Half of Leading Healthcare Organizations Are Not Yet Switching to ICD-10-CM

2011-08-10T09:23:00.004-04:00

A report by HealthLeaders Media finds that nearly half of healthcare leaders have not yet even begun to prepare for the ICD-10-CM switch. Overwhelmed with competing priorities, hospitals and health plans have not started on ICD-10-CM despite a misguided belief that it will help with their quality improvement efforts (72% of respondents) and a real belief that it will negatively impact revenue for years to come (46% of respondents).

Healthcare reform and the electronic health record are higher priorities. Let's turn off the switch.

ICD-10-CM Prerequisite at Risk

2011-08-09T00:07:00.006-04:00

A Medical Management Group Association (MGMA) survey finds that just over 45% of physicians have not begun the process to upgrade to a standard that is a prerequisite for the ICD-10-CM switch. The ICD-10-CM switch requires that doctors and health plans upgrade from a standard called '4010' to its successor, 5010.

The reason: 4010 arbitrarily limited the number of characters for diagnosis codes to the maximum contained in ICD-9-CM: 5. Now, ICD-10-CM has diagnosis codes that stretch to as many as 7 characters. So, before the U.S. can start using ICD-10-CM codes for payment and reimbursement purposes, it must first upgrade the standards for submitting insurance claims.

To be sure, 5010 has other changes intended to improve the standard as well. But also to be sure, ICD-10-CM is a non-starter without it.

So, now comes news that physicians are struggling with the prerequisite to ICD-10-CM, let alone ICD-10-CM itself.

The survey results also mention that the cost of the 5010 upgrade is $16,000 per physician. With approximately 660,000 physicians in the United States today, the cost of the 5010 upgrade is $10.56 billion.

However, the final rule (warning: PDF) that mandated the 5010 upgrade states that "... the new estimate of total cost for physicians and other providers segment to implement Version 5010 is between $544 million to $1,088 million."

Too low by a factor of 9.7!

And this cost dwarfs the rosy estimates of benefit: the final 5010 rule states that "...the new estimate for physician savings due to better standards is $1,392 million and operational savings due to increase in the use of auxiliary claim transactions are $4,443 million".

So the cost already is dwarfing the best-case scenario for benefit by a factor of two.

Given that similar problems exist already with the estimates of cost and benefit of ICD-10-CM, we could save countless healthcare dollars by aborting the switch. Now!

Hospitals: ICD-10 Switch Means the EHR Must Wait

2011-06-17T17:41:00.004-04:00

The American Hospital Association sent a letter (PDF) to the Healthcare Information Technology (HIT) Policy Committee urging a delay in implementing stage 2 of Meaningful Use criteria for electronic medical records (EMRs), in large part because hospitals are otherwise busy in switching to ICD-10-CM.

Both ICD-10-CM and EMR adoption are unfunded mandates of the federal government, although there are incentives for EMR adoption (non-adoption will eventually result in penalties that come in the form of reduced reimbursements per service). To qualify for incentives for EMR adoption, hospitals must demonstrate "meaningful use", and the federal government has set criteria for it. However, the criteria will become more stringent over time. Currently hospitals must meet "Stage 1" criteria.

The letter is about when "Stage 2" meaningful-use criteria should go into effect. Hospitals are saying that the government should delay stage 2 criteria, because the burden of switching to ICD-10-CM is too high.

As we reported here, hospitals previously asked the government to back off on meaningful use because of the switch to ICD-10-CM.

Of course, we think the EMR is more important, and that ICD-10-CM should take the back seat. Nevertheless, it illustrates one significant effect of the ICD-10-CM switch: delayed adoption of EMRs.

ICD-10 or Meaningful Use? Between a rock and a hard place.

2011-05-20T18:18:00.005-04:00

The HIT Policy Steering Committee is debating whether delaying stage 2 of meaningful use would allow healthcare providers more time and resources to negotiate succesfully the switch to ICD-10 (or more precisely, ICD-10-CM and ICD-10-PCS).

The conflict between electronic medical record (EMR) adoption and the switch to ICD-10-CM first surfaced almost immediately after passage of the HITECH Act that incentivizes EMR adoptoin, and is highlighted by a letter from the American Hospital Association and a letter from numerous doctors' organizations.

Despite our prediction that the ICD-10-CM switch would pull resources from meeting MU, it turns out that meeting MU is taking resources from the ICD-10-CM switch.

Now, the HIT Policy Steering Committee is starting to recognize that resource-constrained healthcare providers will have severe difficulties doing both. However, it should have realized this problem much sooner since they certainly were privy to the letters sent above, dated in June, 2009. Almost two years ago!

Now they propose to delay MU "stage 2" criteria, to allow resource-constrained providers to meet the ICD-10-CM mandate.

Why not propose instead that the switch to ICD-10-CM be postponed or even canceled?

Granted, they can only control directly the timing of stage 2 MU, but surely the members of the Steering Committee have some influence with decision makers in Health and Human Services?

Doctors: Regulatory burden crowds out health care reform

2011-04-14T18:47:00.002-04:00

In a letter to Donald Berwick, MD, Administrator of the Centers for Medicare and Medicaid Services, the American Medical Association lists the regulations that have been and continue to be most burdensome to physicians.

I will let the letter speak for itself (emphasis exactly as in original). Note that ACA = Affordable Care Act, the major healthcare reform bill enacted into law in 2010.

The human and technological investments needed to participate in quality incentives are competing for physician time and resources needed to move to an enormous new set of diagnosis codes in ICD-10. The struggle to keep up leaves little time to get engaged in the practice redesign and payment and delivery reforms envisioned in the ACA and detracts from patient care just as the ACA is promising access to millions of uninsured Americans. We strongly urge the Administration and CMS to carefully consider the impact the collision of these compliance deadlines will have on physicians, patients and the ACA’s promise of better care for more people.

The Breathtaking Scope of ICD-10-CM Revisions for 2011

2011-04-09T16:43:00.006-04:00

The Centers for Medicare and Medicaid Services just released a 2011 version of ICD-10-CM. A quick look at the "ICD-10-CM 2010 to 2011 Addenda" reveals a breathtaking scope of change.

First, the "Addenda" document (misnamed, since it also includes things removed and edited, not just added) for the tabular index totals 185 pages in a file nearly 1MB in size. Second, the changes span every chapter of ICD-10-CM.

Worse still, is that numerous codes have undergone a change in meaning, something decried by experts in medical informatics over 16 years ago.

Here is an example:

C64.1 Malignant neoplasm of right kidney, except renal pelvis

is now:

C64.1 Malignant neoplasm of left kidney, except renal pelvis

The update also deletes codes, which also militates against best practices in medical terminology management. Deleted codes include C64.0, C65.0, C66.0.

Anyone trying to update software applications that take advantage of particular codes for logic-based processing will surely have to review all 185 pages very carefully to esnure that their logic remains consistent. DRGs will have to be reviewed as well.

These substantial changes just 1.5 years prior to the deadline to switch will increase the cost and complexity of the switch. Another unwelcome development in the long, sad saga of ICD-10-CM.

Absurd arguments for ICD-10-CM

2011-04-08T19:55:00.004-04:00

Sometimes, the arguments in favor of ICD-10-CM border on the absurd. In the January, 2011 issue of Healthcare IT News, the increased "specificity" of ICD-10-CM is highlighted as improving cost savings and disease management. What evidence are we given? The following list of codes:

I'm sure that there are hundreds of billions of dollars to be saved in the health care system, now that we can only code dolphin and sea lion bites better.

Dr. Joel Diamond, in his Health Interoperability Blog, documents similarly absurd arguments here. One proponent of ICD-10-CM said we'd be better off because we would be able to document not just "sports injury", but also whether the injured party was struck by a basketball, baseball, or football.

Busy clinicians trying to take care of sick patients are the ones we will rely on to code this additional specificity, however. Do we really want to distract them from patient care to find the code for dolphin vs. sea lion bites, or strikings by basketball vs. baseball? Is this really the best use of six-figure talent?

The cost of switching to ICD-10-CM has been underestimated: Proof.

2011-02-08T11:42:00.016-05:00

The Department of Veterans Affairs (VA) is spending $211 million on software and services for the switch to ICD-10-CM. And this expenditure is on a third-party alone, let alone the time its employees are devoting to managing the switch.

So, how does this dollar figure comport with the estimates that various entities made of the costs of the switch to ICD-10-CM?

Well, as it happens, it is well out of bounds of any of the estimates.

First, the RAND report (warning: PDF) that estimated the costs of the switch failed to account for any costs to the VA for the switch. Oops. The RAND report estimated a cost of $425–1,150 million for the switch, so this $211 million expenditure on the part of the VA inflates RAND's estimate by 19-50%.

Therefore, RAND's estimate of the overall cost of the switch is significantly low.

Next, the Department of Health and Human Services (HHS), in its final regulatory rule (warning: PDF) mandating the switch, did account for VA software expenditures to manage the switch. HHS estimated that the VA would spend a total of $24-31.35 million on software and systems, not counting training and planning. Even if we add training and planning (assuming that the contract includes those functions), HHS estimated no more than $113.8 million in spending on software/systems by the VA.

Thus, the $211 million figure is nearly double the amount that HHS expected, at a minimum.

HHS pegged total costs of the switch at ~$2.3-2.6 billion. So this overrun of its estimate for the VA represents 3.7% of the highest estimate by HHS for the total, national cost of the switch.

What other overruns are government agencies, providers, and payers experiencing. In other words, where else, and by how much, are the estimates too low?

Stay tuned.

We have always maintained that the estimates were unrealistically low, and now we have presented proof.

Doctors spending on EMRs instead of ICD-10-CM switch

2011-02-01T09:04:00.003-05:00

As I noted in a previous post, doctors have insufficient resources to both adopt electronic medical records and switch to ICD-10-CM.

As this story indicates, doctors have been focusing resources on meeting the federal government's "meaningful use" criteria for EMRs at the expense of the switch to ICD-10-CM. Specifically, two thirds of physicians responding to a survey reported spending resources on "meaningful use" in favor of ICD-10-CM.

Of course, in my post, I said that the switch would slow down meeting "meaningful use", but it appears that the converse is happening, and that "meaningful use" is slowing down the switch.

Regardless, the switch ought to be deferred to allow physicians to meet "meaningful use".

Family physicians seek ICD-10-CM delay in testimony to Congress

2010-08-02T22:13:00.005-04:00

On July 27, in testimony (warning: PDF) to the House Energy and Commerce Subcommittee on Health titled "Regarding Implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act", Dr. Roland A. Goertz said that implementation of electronic medical records ought to take precedence over the switch to ICD-10-CM.

Dr. Goertz said "...practices are at their maximum capacities for change, and we ask that your committee not make additional requests of these physicians during this transition and even look at the required adoption of ICD-10 as something to delay."

Story on ICD-10 contains inaccuracies

2010-07-01T12:38:00.008-04:00

A story about 3M consulting services to assist hospitals with the transition to ICD-10 contains several gross inaccuracies.

First, it mentions "ICD-10 concepts and terms". ICD-10 does not have concepts and terms, nor does its predecessor ICD-9-CM. It has codes, categories, and titles. The use of the phrase "concepts and terms" is highly misleading as it suggests that ICD-10 is a concept-based terminology. Although I have issues with those as well, they are lightyears of ahead of ICD-10's archaic structure. So the implication is that ICD-10 is something much better than it really is.

Second, the story lists 4 purposes for ICD-coding of diagnosis, and lists the single most important one, reimbursement, last. Were it not for reimbursement and bureaucratic requirements, no one would assign ICD codes for clinical care, quality, or epidemiological purposes.

In summary, this article misleadingly paints a much more favorable picture of ICD-10 than is warranted by the facts.

ICD-10-CM is NOT a nomenclature

2010-04-13T21:41:00.009-04:00

In this article about the lengths to which organizations must go to 'upgrade' to ICD-10-CM, the author refers to ICD-10-CM as a 'nomenclature'.

ICD-10-CM, as its formal name indicates, is a classification, not a nomenclature. Its formal name is the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), as listed on the web site of the government agency that created it from ICD-10.

For example, ICD-10-CM code K83.8 refers to Other specified diseases of the biliary tract. This class of diseases includes multiple individual diseases such as: adhesions of biliary tract, atrophy of biliary tract, hypertrophy of biliary tract, and ulcer of biliary tract.

A nomenclature, by contrast, would have codes for each of these diseases that ICD-10-CM lumps together under the single code K83.8.

So, unfortunately, misinformation about ICD-10-CM continues. Were it truly a nomenclature, and a good one, then it would truly be a worthwhile upgrade.

ICD-10-CM Winners

2010-02-13T16:21:00.005-05:00

The Workgroup for Electronic Data Interchange or WEDI announced the release of its ICD-10 Vendor Resource Directory on Feb 11, 2010.

The companies all listed here stand to benefit financially from the switch to ICD-10-CM, and thus we dub them the "ICD-10-CM winners".

The losers, of course, are your doctor, your hospital, and your health insurance company (if you have one), just for a start. The switch will cost them money.

ICD-10-CM and Windows ME: A Switching Analogy

2009-11-05T14:10:00.009-05:00

Much of the lack of resistance to the switch to ICD-10-CM is based on the presumption that since it is the next "version", it simply must be better. Proponents deride the arguments against the switch as being analogous to the question "MS-DOS works fine, why Windows?"

However, a better operating-system analogy would be "Windows 98 works fine, why Windows ME?"

As those who upgraded to Windows ME can attest, the upgrade was a complete disaster. PC World rated Windows ME as the fourth worst tech product of all time.

Analogously, ICD-10-CM is the last upgrade for the archaic, "statistical classification" architecture of terminologies. ICD-11 will use modern approaches to terminology.

In this sense ICD-10-CM is very much like Windows ME, in that Windows ME was the last MS-DOS based Microsoft OS before Microsoft converted its home OS to the newer, Windows NT architecture.

How ironic.

As naysayers against ICD-10-CM, we are saying that we should skip ICD-10-CM, which is the Windows ME of disease classification. It is the proponents of ICD-10-CM who are arguing for the perpetuation of ancient technology, not the naysayers.

The cost of the switch, briefly revisited

2009-10-07T20:49:00.006-04:00

Prior efforts to estimate of the cost of switching from ICD-9-CM to ICD-10-CM compared the cost to that of Y2K remediation. In a post last year, we also highlighted the comparison.

The American Hospital Association estimates that the cost of Y2K was $8 billion for hospitals. Compare that to the Health and Human Services (HHS) estimate for switching to ICD-10-CM of $1.6 billion.

Now comes the experience of someone who lived through Y2K and now is preparing his hospital for the government-mandated switch.

Stanley Padfield, system director for health information management at four-hospital Lee Memorial Health System, Cape Coral, Fla, considers the cost of the switch to be higher than that of Y2K remediation.

An article describing Padfield's experience notes:

Padfield says tackling the ICD-10 challenge will prove more difficult than Y2K “because there are a lot more variables involved.” Plus, providers that fail to adequately prepare risk not getting paid promptly by Medicare and other payers.

So, the early experience is already that the ICD-10-CM switch will cost hospitals more than the $8 billion they spent on Y2K. Which dwarfs the HHS low-ball figure of $1.6 billion for the entire health care system to switch.

Even the optimistic RAND report that analyzed the cost of the switch could not come up with more than $7.7 billion in benefits to the switch.

So the early signs are that the costs of the ICD-10-CM switch to the health care system will far exceed the benefits.

Background on disease classification and coding

2009-09-07T20:56:00.004-04:00

The Encyclopedia of Public Health on Answers.com has two, concise articles on classification of disease and its history.

For a concise overview on the general task of classifying diseases and the reasons for it, see the Classification of Disease entry.

For a history of disease classification and the International Statistical Classification of Diseases and Related Health Problems (now the official name for ICD, including ICD-10), see this article.

"Meaningful Use" criteria require problem lists in ICD-9 or SNOMED

2009-07-20T19:23:00.005-04:00

As we discussed in previous posts here and here, the "stimulus bill" passed by Congress earlier this year increases Medicare and Medicaid payments to physicians and hospitals who are "meaningful users" of electronic medical records (EMRs) in coming years.

The linchpin to the payments is the definition of "meaningful use", which the law mandates that the Department of Health and Human Services (HHS) define. The law also mandated the formation of the Healthcare Information Technology (HIT) Policy committee, and it is this committee that is currently conducting hearings into what the criteria for "meaningful use" should be. Ultimately, HHS will define meaningful use through a rulemaking process similar to the one that led to the mandate to switch to ICD-10-CM.

Well, the latest "matrix" (warning: pdf) of meaningful use criteria stipulate that the EMR must maintain problem lists in either ICD-9 or SNOMED.

We think they are both terrible choices. Problem lists maintained in either system are not likely to be very meaningful at all.

Doctors: ICD-10 Switch Inhibits "Meaningful Use" of EMRs

2009-06-30T06:42:00.005-04:00

For a brief introduction to federal incentives for adoption of electronic medical records (EMRs), see yesterday's post.

In response to a request for comments on proposed rules for meaningful use, over 80 physician organizations joined forces behind a letter to the Office of the National Coordinator for Health Information Technology (ONCHIT). This letter outlines the unanimous opinion of these organizations on what the "meaningful use" criteria for EMRs should be.

The 80 organizations include the American Medical Association, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Radiology, the American College of Surgeons, the American College of Physicians, and numerous state medical societies.

In an attachment to the letter, these doctors' organizations note that in setting the timing of EMR implementation, ONCHIT should ...Factor in the Implementation of Version 5010, ICD-10, and Other Related Compliance Deadlines.

The attachment goes on to say:

The health care industry, including physicians, will be migrating to the next version of HIPAA electronic transactions standards,Version 5010, by January 1, 2012. Moreover, the transition from using ICD-9 to ICD-10 codes must occur by October 1, 2013 which is expected to be an even more complex undertaking than the adoption of the first version of HIPAA standards (4010) and the transition to use of the National Provider Identifier (NPI). The implementation timeframe must factor in vendor, physician, and other health care partner readiness for all of these significant transitions that will occur simultaneously with the incorporation of HHS’ recommended standards for qualifying EHRs.

Which ultimately means that physicians, in addition to hospitals, expect the switch to ICD-10-CM to slow them down significantly with respect to becoming "meaningful users" of EMRs.

Hospitals: ICD-10 Switch Inhibits "Meaningful Use" of EMRs

2009-06-29T21:02:00.004-04:00

The "stimulus package"--more formally known as the American Recovery and Reinvestment Act of 2009--promises doctors and hospitals increased reimbursement from Medicare and Medicaid if they become "meaningful users" of electronic medical records (EMRs). Of course, the Act leaves open the definition of meaningful use, leading to yet another rulemaking process similar to the one that produced the mandate to switch to ICD-10-CM.

In its comments to the Office of the National Coordinator for Health Information Technology (ONCHIT), the American Hospital Association (AHA) correctly recognizes that the switch to ICD-10-CM will drain away resources from their efforts to become meaningful users of EMRs. In response, the AHA says that ONCHIT should slow down and lighten the criteria for "meaningful use."

The AHA comments (warning: pdf) say:

Staging the requirements and use levels in the definition also should recognize other HIT initiatives already underway and the likely vendor and workforce constraints hospitals may face. Hospitals are required to move to the new X12 Version of 5010 HIPAA standards in 2010 and ICD-10 in 2013. The AHA also is concerned that vendors will not be able to improve, test, implement and support HIT systems in hospitals nationwide due to the increased and simultaneous demand for HIT services and products. Vendor and hospital IT workforce capacity constraints should be considered as well.

In other words, the switch to ICD-10-CM will pull resources away from hospitals' ability to achieve meaningful use of EMRs.

A "monstrous task", "like a heart transplant."

2009-06-18T07:12:00.010-04:00

These are the words of those who are starting to investigate the true cost and effort of switching to ICD-10-CM, as quoted in an article about the Healthcare Financial Management Association's annual Healthcare Finance Conference.

Orlando Health has found that the switch will affect 90% of all of its information systems. Integris Health of Oklahoma City has found that the switch will require "changes in data flow," "broad testing," and "intensive staff education".

The American Health Information Management Association (AHIMA), cheerleader for the switch to ICD-10-CM, recommends that you "establish a multi-disciplinary planning team involving all departments" now as a first step for making the transition.

If we're going to expend such resources to switch, why are we adopting a system whose core structure and framework is from the era of punchcards and paper charts?

In other words, if we're going to do a heart transplant, shouldn't we put in a good heart?

Diagnosis classification GEMs

2009-05-06T07:08:00.015-04:00

The Center for Medicare and Medicaid Services (CMS) is sponsoring a conference call to discuss "ICD-10-CM/PCS Implementation and General Equivalence Mappings (Crosswalks)".

The purpose of the call is to discuss "...the General Equivalence Mappings that have been created to assist in converting policies, edits, and trend data from ICD-9-CM to ICD-10-CM/PCS."

In other words, to help the switch to ICD-10-CM from ICD-9-CM go more smoothly, CMS is betting on "General Equivalence Mappings" to help people convert their ICD-9-CM encoded data to ICD-10-CM encoded data. A transition plan might therefore involve continuing to code with ICD-9-CM and then converting those codes to ICD-10-CM. (!)

Sounds easy, right?

That is doubtful.

First, we want to point out the irony of this policy. We were told over and over that we'd get better data from ICD-10-CM coding and the sooner the better. Now, we're being told we can continue coding along merrily in ICD-9-CM and just convert our data to ICD-10-CM afterwards. How could that possibly result in better data?

Furthermore, to use the General Equivalence Mappings (or GEMs), you need to know the following facts, taken from the materials CMS posted for the conference call:

- ICD-9 and ICD-10 codes are quite different

- One ICD-9 Diagnosis Code may be represented by multiple ICD-10 codes

- One ICD-10 Diagnosis Code may be represented by multiple ICD-9 codes

- A few ICD-10 codes have no predecessor ICD-9 codes

- Some payers found GEM detail daunting, therefore they developed a "reimbursement mapping" which is much simpler. It is not clear when to use this mapping vs. GEMs.

- There may be multiple translation alternatives for a source system code (the code being looked up), all of which are equally plausible. This is true of both the ICD-10 to ICD-9-CM GEMs and the ICD-9-CM to ICD-10 GEMs.

- A one-to-one mapping does not imply that the two codes refer to the same disease!

- There are instances where there is not a mapping between an ICD-9-CM code and an ICD-10 code. In these instances, CMS has flagged the code with a "no map" flag.

- Each GEM has FIVE flags:
        1. The "approximate" flag
        2. The "no map" flag
        3. A flag to indicate a one-to-many mapping
        4. and 5. Two flags to "further clarify one-to-many mappings".

- CMS et al. developed GEMs "...independently without reference to Medicare data."

- The ultimate goal of the GEMs, and the primary basis on which they are maintained and evaluated, is whether a given patient record receives the SAME Medicare Severity Diagnosis Related Group. Essentially, this means that the improved diagnostic precision of ICD-10-CM is irrelevant to how Medicare will reimburse hospital stays.

- The net effect of the switch and the GEMs on "trend data" (for example, the incidence of hypertension or type 2 diabetes mellitus over time) is not known, and CMS will monitor the effect after the switch.

Why are we switching again?

ICD-10-CM cannot save the personal health record

2009-04-13T21:02:00.000-04:00

In a Boston Globe article, several so-called experts obtusely suggest that the switch to ICD-10-CM will improve the quality of data in personal health records.

First, we must briefly say what is a personal health record (PHR). Then, we will recap the Globe story. Finally, we will illustrate that the use of ICD-10-CM in place of ICD-9-CM could not have helped the gentleman in the story.

Wikipedia defines a personal health record as ...a health record that is initiated and maintained by an individual. This definition does not account for the recent trend of companies like Google and Microsoft setting up personal health records, whereby health care providers and payers also contribute data to alleviate the amount of data entry required by the person.

The Boston Globe article recounts the story of Dave deBronkart, who set up a PHR with Google. Google helped transfer claims data into his PHR from a Beth Israel Deaconess Medical Center.

Mr. deBronkart was subsequently alarmed to see a diagnosis in his PHR of spread of his cancer to his brain or spine. You see, Mr. deBronkart has a history of kidney cancer. But it had previously spread to his skull, not his brain or spine. But there is no ICD-9-CM code for spread of cancer to the skull, so the experts quoted in the article understandably postulate that medical records coders used instead codes for spread to brain and/or spine.

But two experts, Drs. John Halamka and Roni Zeiger, then go on to claim that ...the records will improve as more precise coding language is adopted in the coming years. The article does not mention the particular coding system they had in mind, but since the data in question was claims data, it is hard to imagine otherwise.

So, could the switch to ICD-10-CM have prevented the unnecessary fright experienced by Mr. deBronkart?

NO.

ICD-10-CM has the C64 family of codes for malignant neoplasm of kidney (his primary cancer that subsequently spread to his skull), including C64.0 (right kidney), C64.1 (left kidney), and C64.9 (unspecified kidney).

It also has C79.31 - Secondary malignant neoplasm of brain and C79.51 - Secondary malignant neoplasm of bone.

But ICD-10-CM has no code for secondary malignant neoplasm of the skull.

You cannot use C41.0 - Malignant neoplasm of bones of skull and face, because that code must be used only for cancers of bone that arise in the skull and face, not for any cancer that spreads to the skull or face from somewhere else.

And that's it. There are no other even-close-to-relevant codes.

So much for any benefit to ICD-10-CM to help Mr. deBronkart.

Final rule for ICD-10-CM survives Obama administration review

2009-03-12T07:36:00.002-04:00

HHS' final rule mandating ICD-10-CM has passed muster with the Obama administration. The rules will proceed unaltered, and thus the final compliance date for ICD-10-CM is Oct 1, 2013.

Hospitals, physicians, clinical laboratories, health plans, the federal government itself, state governments, nursing homes, and more will all now spend an estimated $1 billion to upgrade from a bad disease coding system to a slightly less bad, but unnecessarily more complicated, one.

Final ICD-10-CM rule likely on hold for review

2009-01-26T21:00:00.000-05:00

The Obama administration has held for review all rules that either have not been published or have not yet taken legal effect. The latter condition applies to the final ICD-10-CM rule, because it does not take effect till March 17.

It's a long shot, but perhaps the review will lead the Obama administration to realize what a mistake the ICD-10-CM switch is.

The 318 ICD-10-CM codes for diabetes mellitus

2009-01-20T07:43:00.000-05:00

In a previous post, we pointed out that despite the fact that there are very few known subtypes of diabetes mellitus, ICD-10-CM has approximately 290 codes for diabetes mellitus, not counting gestational diabetes mellitus.

In the 2009 release of ICD-10-CM, we count a total of 318 codes for diabetes mellitus, including gestational diabetes mellitus. The reason for the large number of codes is that ICD-10-CM combines multiple disease classes into a single code.

For example, the ICD-10-CM code E11.621 Type 2 diabetes mellitus with foot ulcer, contains two disease classes: diabetes mellitus and foot ulcer. For sure, this code implicitly means that the former caused the latter (note that this causal relationship is inaccessible to the computer), but that augments our point. Nothing is its own cause and thus these two diseases are distinct.

We provide here on Google docs the 318 codes and their text strings, in a spreadsheet format that anyone can at least copy-and-paste into their own spreadsheet or database table. An easy way to demonstrate the needless complexity caused by combination codes.

Myth: SNOMED CT has more disease codes than ICD-10-CM

2009-01-18T18:18:00.000-05:00

Because SNOMED CT is a reference terminology, and ICD-10-CM a disease classification, one might think that SNOMED CT would have more disease codes because it reaches a higher level of diagnostic precision (what the ICD-10-CM proponents ambiguously refer to as "specificity") than ICD-10-CM.

One would be wrong, however. We already busted this myth in a previous post, but we give it its own post to highlight the absurdity that is ICD-10-CM.

Per the final rule (warning: pdf) to adopt ICD-10-CM, ICD-10-CM has approximately 68,000 codes. SNOMED CT (the July, 2008 version), by contrast, has 63,731 active disease codes.

ICD-10-CM therefore has approximately 7% MORE disease codes than SNOMED CT. Assuming of course, that ICD-10-CM contains only codes for diseases, which it doesn't. It has codes for lots of other things, like symptoms of disease. If there were any way to count automatically how many ICD-10-CM codes represented diseases as opposed to something else, it would be possible to do an actual apples-to-apples comparison.

But, since ICD-10-CM says it classifies diseases (and not other things) and gives no way to infer automatically (i.e., by computer) whether it classifies other things than disease, we feel justified in making this comparison. It highlights another absurdity of ICD-10-CM: it isn't (entirely) what it says it is.

It's final: ICD-10-CM by Oct 1, 2013

2009-01-16T21:43:00.000-05:00

The Department of Health and Human Services issued today a final rule (warning: pdf) mandating the adoption of ICD-10-CM as a code set under the Health Insurance Portability and Accountability Act (HIPAA). It pushed back the deadline from Oct 1, 2011 (from its proposed rule last August) to Oct 1, 2013.

At approximately the same time, the National Center for Health Statistics released a new, 2009 version of ICD-10-CM that is available here. Instead of the 23MB, 2,392 page PDF file of the 2007 format, we now have an 8.8MB, 2,369 page PDF file. A trimming of 1% on the page count, and a shrinking of over 50% in file size.

The health care industry now has a little more than 4.5 years to find every usage of ICD-9-CM codes in all of its systems, and upgrade and test them to use ICD-10-CM. All the effort spent on that, will not be spent on adopting electronic medical records, devising and participating in pay for performance programs, improving patient safety, automating the reporting of notifiable diseases, chronic disease management, quality initiatives, adopting other information technology standards for true interoperability, and the list goes on.

ICD-10-CM fails every basic requirement demanded of modern technology, terminology, and ontology, and yet it--and previously ICD-9-CM which also fails to meet these requirements--are the only code sets the government has mandated the industry adopt en masse. We suppose it's not surprising coming from a government bureaucracy. But it still is senseless.

Myth: It is practical to assign ICD-10-CM codes manually

2008-12-17T08:03:00.000-05:00

The proposed rule to mandate the switch to ICD-10-CM states:

It would be impractical to attempt to manually assign SNOMED–CT codes. The number of terms and level of detail in a reference of clinical terminology such as SNOMED CT cannot be effectively managed without automation,...

By implication, then, it would be practical to assign ICD-10-CM codes manually. Otherwise this supposed disadvantage of SNOMED-CT would not be a factor in HHS' decision to reject SNOMED-CT.

Let us examine this claim further.

ICD-10-CM, by all accounts we have seen--including the proposed rule itself, contains approximately 68,000 codes.

First, we think the very notion that the human brain can cope with 68,000 codes and reliably and manually assign a few of them correctly to patient visits or hospitalizations has no face validity.

Second, even with the manual assignment of the 13,000 codes of ICD-9-CM, there is and has been tremendous variability and low reliability. The Department of Veterans Affairs (VA) conducted a study that found substantial variability in assignment of ICD-9-CM codes:

Based on this study, OHI concluded that the coding of the primary and secondary diagnoses varied widely. The implications of this variability has to be considered when assessing the validity of health services research, health care program planning, quality assurance, utilization review, and resource allocation for VA Medical Centers based on ICD-9-CM codes or DRG information.

While OHI was not evaluating the coding "error rate" in this study, the coding variability observed in the study was comparable to error rates noted in earlier Institute of Medicine (IOM) studies. We found a 60.6 percent agreement in the primary diagnosis code among the original coders and our expert coder. The IOM studies documented a 65.2 percent agreement on the principal diagnosis code, in 1977, and a 63.4 percent agreement on the principal diagnosis code of the records analyzed in 1980. Thus, in all three studies there was approximately a 2/3's agreement in the coding of the medical record.

Even among the expert coders, there was a 19 percent disagreement on the primary diagnosis code. Since our expert coders were highly qualified, this high rate of disagreement caused OHI to question the reliability of the selection of the primary diagnosis and, thus, the accuracy of coded information.

A study of ICD-9-CM coding in psychiatry concluded:

The question was addressed how well mental health professionals were able to translate diagnostic formulations into ICD-9-CM codes. This was done with three coder groups and under two conditions. It was found that there was insufficient interrater agreement on the ICD-codes in all groups and conditions. This finding then was related to the inadequacies of the ICD-system itself. It was concluded that current mental health statistics that are based on the ICD-9-CM coding system are without scientific value.

A study of ICD-9-CM coding in intensive care concluded:

In a multicenter database designed primarily for epidemiological and cohort studies in ICU patients, the coding of medical diagnoses varied between different observers. This could limit the interpretation and validity of research and epidemiological programs using diagnoses as inclusion criteria.

Since other nations have already switched to ICD-10 or their own national variant of it (none of which has even half as many as 68,000 codes), what has their experience been with ICD-10? Better coding? No.

One study of the reliability of coding with ICD-10 concluded:

The refinement of the ICD-10 accompanied by innumerous coding rules has established a complex environment that leads to significant uncertainties even for experts. Use of coded data for quality management, health care financing, and health care policy requires a remarkable simplification of ICD-10 to receive a valid image of health care reality.

A study from Canada even compared the quality of coding between ICD-9 and ICD-10 and concluded:

The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM.

So then, manual assignment of ~13,000 ICD-9-CM codes in the U.S. and elsewhere, and the manual assignment of ~13,000-30,000 ICD-10 codes (depending on national variant), have not been "effectively managed".

It brings to mind the old adage, those who live in glass houses should not throw stones.

So what of SNOMED-CT? How many disease codes are we looking at?

The July, 2008 version of SNOMED-CT, by contrast, has 63,731 active disease concepts. ^[1]

SNOMED-CT, therefore, actually has fewer disease codes than ICD-10-CM! It is hard to imagine that manual assignment of SNOMED-CT disease codes could be managed any less effectively than manual assignment of ICD-10-CM disease codes.^[2]

Myth: Busted.

^[1]Because SNOMED-CT, unlike ICD-10-CM, comes in machine-readable format, these kinds of exact counts are easy to make.

^[2]Note that we are not advocating SNOMED-CT for disease coding. And studies conducted thus far have shown lack of reliability in SNOMED-CT disease coding as well.

Could ICD-10-CM reduce the primary care workforce?

2008-11-18T07:09:00.000-05:00

On the heels of primary-care opposition to the switch to ICD-10-CM comes news of a survey that shows half of primary-care doctors would quit medicine today if they could. The major reason? Insurance-company and government red tape.

Well, the switch to ICD-10-CM is a big roll of federal-government red tape. Will this additional red tape from the federal government lower the threshold for many primary care physicians to leave medicine?

For starters, we'll let them tell you themselves.

The letter by the American College of Physicians on behalf of its Internist members states: The burden associated with implementing ICD-10-CM is likely to exacerbate the crisis in the primary care workforce.

The letter by the American Academy of Family Physicians (AAFP) was somewhat less pointed but no less clear: CMS must realistically consider whether pressures to rapidly adopt the ICD-10-CM code set outweigh the importance of supporting the already fragile backbone of patient care, primary care medicine.

The survey of primary-care physicians obtained responses from an impressive 12,000 doctors, 4000 of whom took the time to provide written comments. Here are some key findings of the survey:

49% of physicians -- more than 150,000 doctors nationwide -- said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.
94% said the time they devote to non-clinical paperwork in the last three years has increased, and 63% said that the same paperwork has caused them to spend less time per patient.
82% of doctors said their practices would be "unsustainable" if proposed cuts to Medicare reimbursement were made.
60% of doctors would not recommend medicine as a career to young people.
If they had the financial means, 45% of doctors would retire today.
Only 6% of physicians described the professional morale of their colleagues as “positive.” 42% of physicians said the professional morale of their colleagues is either “poor” or “very low”.
78% of physicians said medicine is either “no longer rewarding” or “less rewarding”.

Instead of throwing these physicians a lifeline, the government is throwing them an anchor (ICD-10-CM). Many will very likely drown (leave practice) as a result.

Internists oppose the switch to ICD-10-CM, too

2008-11-16T13:53:00.001-05:00

In yesterday's post, we highlighted the opposition of family physicians to the switch to ICD-10-CM.

It turns out that internists, too, are against the switch. Dr. Yul Ejnes wrote a letter (pdf) on behalf of the American College of Physicians (ACP) opposing the switch. Like the AAFP letter (pdf), Ejnes' letter was in response to the proposed rule to mandate a switch.

Here are some highlights from internists' opposition to the switch:

The College urges the Centers for Medicare and Medicaid Services (CMS) to suspend plans to adopt ICD-10-CM, the diagnosis code portion of the ICD-10 set, for physicians and other outpatient entities. Adoption of this diagnosis code set in the ambulatory setting is unwarranted as the collective costs far out-weigh the benefits...The burden associated with implementing ICD-10-CM is likely to exacerbate the crisis in the primary care workforce.

The administrative changes and related costs of ICD-10 adoption at this time will place a significant burden on internal medicine and all other physicians; with the burden especially acute for primary care physicians. This is at a time when physician practices—small primary care practices--are already struggling to meet:

other regulatory requirements (e.g. other HIPAA related initiatives including implementation of the National Provider Indicator (NPI) and the upcoming adoption of the 5010 transaction standards);
calls for increased adoption of HIT (e.g. e-prescribing and interoperable electronic health records (EHR) systems) including the recently passed Medicare e-prescribing bonus that transitions into a payment reduction; and
expectations to participate in various pay-for-quality initiatives such as the Medicare Physician Quality Reporting Initiative (PQRI).

Providing more diagnostic code options is not guaranteed to generate better data or patient care.

Indeed, the problems with ICD-10-CM that we have outlined here make it certain that our data will not be better if we switch.

Two of the major primary care specialties, specialties on which hopes for health care reform are often founded, have weighed in. ICD-10-CM will not help them care for patients. Instead, the switch would burden them unnecessarily and impede their ability to care for patients.

Family physicians oppose switch to ICD-10-CM

2008-11-15T21:38:00.000-05:00

Much of the opposition to HHS' proposed rule to adopt ICD-10-CM is about the timeline. They have drunk the ICD-10-CM kool-aid, as it were, and simply ask for more time to make the switch from ICD-9-CM.

However, we recently uncovered opposition to switching at all. On behalf of the American Academy of Family Physicians (AAFP), Dr. Jim King writes a letter in response to the proposed rule.

Here are some highlights of the letter:

The AAFP does not support the transition to ICD-10-CM because we do not find that there is good rationale for making such a significant change.

The purported benefits of the transition to 68,000 ICD-10-CM diagnosis codes are largely based on assumptions and not supported with any real world trial involving practicing physicians in the United States.

Our recommendation that CMS not adopt ICD-10-CM is further supported with the following:

Enhancement and adoption of electronic health records (EHR) must come first
ICD-9-CM diagnosis codes meet the needs of patient care
Biosurveillance and research needs can be met through the mapping of ICD-9-CM to ICD-10-CM
Disease management programs are not dependent on diagnosis codes
CMS’s estimates of coding education needs are not accurate
Changes required for adoption of ICD-10 are substantial
Lack of resources to support physician adoption

The AAFP is the premier speciality society for family physicians. Dr. King is Chair of the Board of the AAFP.

The AAFP has been at the vanguard of electronic health record (EHR) adoption. They have been a key driving force behind the creation of health care information technology standards, including the continuity of care record and continuity of care document.

This opposition does not therefore come from a small, fringe group. Nor does it come from a group that is backwards in its thinking with respect to health care information technology.

The Centers for Medicare and Medicaid Services would do well to listen to those doctors who are at the forefront of using information technology to improve healthcare. They should drop their plan to switch to ICD-10-CM.

As a postscript, we note that in our third post, we criticized the AAFP for not opposing the switch. We hereby withdraw that criticism!

The blogosphere recognizes the pitfalls of ICD-10-CM

2008-11-05T07:25:00.000-05:00

The blogosphere is coming to the realization that ICD-10-CM has substantial problems.

Dr. Wes, in a post on October 25th entitled "Ten Times the Fun," laments:

Imagine, 290 codes just for diabetes! Yeeeee haaaaa! Diabetes with foot ulcers on the right foot gets one code, diabetes with foot ulcers on the left foot gets another code, diabetes with foot ulcers on both feet, but not involving the shins gets another code... I mean, a new code for every nuance of disease! You get the drift! Isn't this SPECIAL? Just think of the COST SAVINGS those clever bureaucrats have found!

Meanwhile, Richard Elmore in a post on his Healthcare Technology News blog on October 29th, entitled "More painful than an insect bite? ICD-10 cost-benefit for healthcare providers," lists all 87 ICD-10-CM codes for diagnoses of insect bites. These 87 codes replace 18 ICD-9-CM codes, a 4.8 fold increase.

Mr. HISTalk linked to Dr Wes' post in his October 27th entry. Mr. HISTalk also linked to Richard Elmore's post in his October 31st entry.

Readers of Mr. HISTalk are similarly not impressed with ICD-10-CM. Comments from Mr. HISTalk readers (not including the comments of yours truly) include the following:

The lists of codes are in general a slavish enumeration of nearly every possible combination of pathology, anatomic location, laterality, and ordinality of visit.

They [NCHS] are distributing it [ICD-10-CM] in a text file to:

1. Reduce the most “arduous” task - writing an upload and deduplication routine
2. Keep a non-Government entity (3M?) on the payroll to “manage” the process for them

Disease classification as patronage?

The blogosphere isn't fooled. ICD-10-CM is a poorly designed and executed boondoggle.

Combination code explosion: An illustration

2008-10-27T21:00:00.000-04:00

The Blue Cross Blue Shield Association highlights the complexity of ICD-10-CM in a presentation on its web site.

On slide 9 of the presentation is a nice illustration of how ICD-10-CM takes a single code from ICD-10 and explodes it out into 144 codes. ICD-10-CM is based on ICD-10 from the World Health Organization. Individual member countries may modify ICD-10 within certain constraints. Australia (ICD-10-AM) and Canada (ICD-10-CA) both have made modifications.

Well, when the National Center for Health Statistics modified ICD-10 to create the United States' clinical modification or ICD-10-CM, it frequently took one or a small number of ICD-10 codes and "expanded" them out to a much larger number of combination codes.

Going back to the illustration of combination-code explosion from the BCBSA, ICD-10 has code S42.0 for fracture of the clavicle (the clavicle is also commonly referred to as the collar bone).

Canada chose to expand this code out to eight codes in ICD-10-CA:

S42.01 - fracture of sternal end of clavicle
S42.01 - fracture of shaft of clavicle
S42.02 - fracture of acromial end of clavicle
S42.09 - fracture of unspecified part of clavicle
S47 - multiple fractures of clavicle
M84.11 - nonunion, shoulder region
M84.21 - delayed union, shoulder region
M84.22 - malunion, shoulder region

Below, we list the 144, seven-character ICD-10-CM codes for fracture of the clavicle. The 144 codes add laterality, whether the fracture is displaced and if so in what direction, and information about which encounter and whether there is "routine healing", malunion, and so on. Note that all the four-, five-, and six-character codes beginning with S42.0 (it is typical in ICD not to count the decimal point as a character) are also part of ICD-10-CM. There are 1 four-character, 4 five-character, and 24 six-character codes, for a grand total of 173 codes, although only the 144 seven-character codes will be valid for reimbursement (in all likelihood).

From one code to 173 codes as we go from ICD-10 to ICD-10-CM. Combinatorial explosion.

ICD-10: ~12,000-13,000 codes
ICD-10-AM: ~16,000 codes
ICD-10-CA: ~30,000 codes
ICD-10-CM: >68,000 codes

The 144, seven-character ICD-10-CM codes for fracture of the clavicle (with thanks to the BCBSA):

S42.001A Unspecified part of right clavicle, initial encounter for closed fracture
S42.001D Unspecified part of right clavicle, subsequent encounter for fracture with routine healing
S42.001G Unspecified part of right clavicle, subsequent encounter for fracture with delayed healing
S42.001K Unspecified part of right clavicle, subsequent encounter for fracture with nonunion
S42.001P Unspecified part of right clavicle, subsequent encounter for fracture with malunion
S42.001S Unspecified part of right clavicle, sequalae
S42.002A Unspecified part of left clavicle, initial encounter for closed fracture
S42.002D Unspecified part of left clavicle, subsequent encounter for fracture with routine healing
S42.002G Unspecified part of left clavicle, subsequent encounter for fracture with delayed healing
S42.002K Unspecified part of left clavicle, subsequent encounter for fracture with nonunion
S42.002P Unspecified part of left clavicle, subsequent encounter for fracture with malunion
S42.002S Unspecified part of left clavicle, sequalae
S42.009A Unspecified part of unspecified clavicle, initial encounter for closed fracture
S42.009D Unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.009G Unspecified part of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.009K Unspecified part of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.009P Unspecified part of unspecified clavicle, subsequent encounter for fracture with malunion
S42.009S Unspecified part of unspecified clavicle, sequalae
S42.011A Anterior displaced fracture of sternal end of right clavicle, initial encounter for closed fracture
S42.011D Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with routine healing
S42.011G Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with delayed healing
S42.011K Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with nonunion
S42.011P Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with malunion
S42.011S Anterior displaced fracture of sternal end of right clavicle, sequalae
S42.012A Anterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture
S42.012D Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with routine healing
S42.012G Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with delayed healing
S42.012K Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with nonunion
S42.012P Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with malunion
S42.012S Anterior displaced fracture of sternal end of left clavicle, sequalae
S42.013A Anterior displaced fracture of sternal end of unspecified clavicle, initial encounter for closed fracture
S42.013D Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.013G Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.013K Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.013P Anterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with malunion
S42.013S Anterior displaced fracture of sternal end of unspecified clavicle, sequalae
S42.014A Posterior displaced fracture of sternal end of right clavicle, initial encounter for closed fracture
S42.014D Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with routine healing
S42.014G Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with delayed healing
S42.014K Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with nonunion
S42.014P Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for fracture with malunion
S42.014S Posterior displaced fracture of sternal end of right clavicle, sequalae
S42.015A Posterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture
S42.015D Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with routine healing
S42.015G Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with delayed healing
S42.015K Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with nonunion
S42.015P Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for fracture with malunion
S42.015S Posterior displaced fracture of sternal end of left clavicle, sequalae
S42.016A Posterior displaced fracture of sternal end of unspecified clavicle, initial encounter for closed fracture
S42.016D Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.016G Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.016K Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.016P Posterior displaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with malunion
S42.016S Posterior displaced fracture of sternal end of unspecified clavicle, sequalae
S42.017A Nondisplaced fracture of sternal end of right clavicle, initial encounter for closed fracture
S42.017D Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with routine healing
S42.017G Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with delayed healing
S42.017K Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with nonunion
S42.017P Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for fracture with malunion
S42.017S Nondisplaced fracture of sternal end of right clavicle, sequalae
S42.018A Nondisplaced fracture of sternal end of left clavicle, initial encounter for closed fracture
S42.018D Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with routine healing
S42.018G Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with delayed healing
S42.018K Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with nonunion
S42.018P Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for fracture with malunion
S42.018S Nondisplaced fracture of sternal end of left clavicle, sequalae
S42.019A Nondisplaced fracture of sternal end of unspecified clavicle, initial encounter for closed fracture
S42.019D Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.019G Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.019K Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.019P Nondisplaced fracture of sternal end of unspecified clavicle, subsequent encounter for fracture with malunion
S42.019S Nondisplaced fracture of sternal end of unspecified clavicle, sequalae
S42.021A Displaced fracture of shaft of right clavicle, initial encounter for closed fracture
S42.021D Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with routine healing
S42.021G Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with delayed healing
S42.021K Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with nonunion
S42.021P Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with malunion
S42.021S Displaced fracture of shaft of right clavicle, sequalae
S42.022A Displaced fracture of shaft of left clavicle, initial encounter for closed fracture
S42.022D Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing
S42.022G Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with delayed healing
S42.022K Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with nonunion
S42.022P Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with malunion
S42.022S Displaced fracture of shaft of left clavicle, sequalae
S42.023A Displaced fracture of shaft of unspecified clavicle, initial encounter for closed fracture
S42.023D Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.023G Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.023K Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.023P Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with malunion
S42.023S Displaced fracture of shaft of unspecified clavicle, sequalae
S42.024A Nondisplaced fracture of shaft of right clavicle, initial encounter for closed fracture
S42.024D Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with routine healing
S42.024G Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with delayed healing
S42.024K Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with nonunion
S42.024P Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with malunion
S42.024S Nondisplaced fracture of shaft of right clavicle, sequalae
S42.025A Nondisplaced fracture of shaft of left clavicle, initial encounter for closed fracture
S42.025D Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing
S42.025G Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with delayed healing
S42.025K Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with nonunion
S42.025P Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with malunion
S42.025S Nondisplaced fracture of shaft of left clavicle, sequalae
S42.026A Nondisplaced fracture of shaft of unspecified clavicle, initial encounter for closed fracture
S42.026D Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.026G Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.026K Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.026P Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with malunion
S42.026S Nondisplaced fracture of shaft of unspecified clavicle, sequalae
S42.031A Displaced fracture of lateral end of right clavicle, initial encounter for closed fracture
S42.031D Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with routine healing
S42.031G Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with delayed healing
S42.031K Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with nonunion
S42.031P Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with malunion
S42.031S Displaced fracture of lateral end of right clavicle, sequalae
S42.032A Displaced fracture of lateral end of left clavicle, initial encounter for closed fracture
S42.032D Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with routine healing
S42.032G Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with delayed healing
S42.032K Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with nonunion
S42.032P Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with malunion
S42.032S Displaced fracture of lateral end of left clavicle, sequalae
S42.033A Displaced fracture of lateral end of unspecified clavicle, initial encounter for closed fracture
S42.033D Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.033G Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.033K Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.033P Displaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with malunion
S42.033S Displaced fracture of lateral end of unspecified clavicle, sequalae
S42.034A Nondisplaced fracture of lateral end of right clavicle, initial encounter for closed fracture
S42.034D Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with routine healing
S42.034G Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with delayed healing
S42.034K Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with nonunion
S42.034P Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for fracture with malunion
S42.034S Nondisplaced fracture of lateral end of right clavicle, sequalae
S42.035A Nondisplaced fracture of lateral end of left clavicle, initial encounter for closed fracture
S42.035D Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with routine healing
S42.035G Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with delayed healing
S42.035K Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with nonunion
S42.035P Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for fracture with malunion
S42.035S Nondisplaced fracture of lateral end of left clavicle, sequalae
S42.036A Nondisplaced fracture of lateral end of unspecified clavicle, initial encounter for closed fracture
S42.036D Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with routine healing
S42.036G Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with delayed healing
S42.036K Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with nonunion
S42.036P Nondisplaced fracture of lateral end of unspecified clavicle, subsequent encounter for fracture with malunion
S42.036S Nondisplaced fracture of lateral end of unspecified clavicle, sequalae

More On Diagnostic Precision

2008-10-24T22:14:00.000-04:00

We say that a diagnosis of disease A is more precise than a diagnosis of disease B if disease A is a subtype of disease B. For example, a diagnosis of coronary artery disease is more precise than a diagnosis of heart disease, and a diagnosis of stenosis of the left anterior descending coronary artery is more precise than a diagnosis of coronary artery disease.

One big reason that ICD-10-CM proponents want to switch from ICD-9-CM is that the disease classes of ICD-9-CM are often not at a sufficient level of diagnostic precision to support many "secondary" uses of health care data, such as rewarding doctors and hospitals for improving quality of care, medical research, chronic disease management, and so on.

For sure, ICD-9-CM is not sufficient for patient care, because to treat patients you need to record the individual diseases, not the classes into which they go.

Because ICD-10-CM is also a classification of diseases, as opposed to a set of codes for individual diseases, it is likely that even with ICD-10-CM, we will still be wanting for increased diagnostic precision. Again, for patient care we need to code individual diseases, not disease classes. Thus, no disease classification will ever be sufficient for patient care.

However, already there are even secondary uses of health care data that require higher diagnostic precision than that provided by ICD-10-CM.

At least one researcher wants to study patients with type 1a diabetes mellitus, and thus wishes to exclude patients with type 1b diabetes mellitus from the study. However, ICD-10-CM does not provide codes for these two subtypes of type 1 diabetes mellitus. This researcher will not be helped by ICD-10-CM, but will still have to test all patients with type 1 diabetes mellitus to determine which subtype they have.

We need a disease-coding system, not a disease-classification coding system. We should not switch to ICD-10-CM.

Decoupling Disease Coding from Disease Classification

2008-10-24T09:19:00.001-04:00

We have hinted at a proposed alternative to ICD-10-CM for coding diagnoses: each diagnosis should receive its own code. Or, to be more specific, since a diagnosis is a conclusion about what disease a patient has, each disease should receive its own code.

In a prior post, we pointed out that ICD-10-CM is a disease classification, and thus the two diseases typhoid endocarditis and typhoid myocarditis both get the same code A01.02, which is really the code for the class of diseases called typhoid fever with heart involvement.

Instead, we propose that all three diseases get a code. Typhoid fever with heart involvement (perhaps inflammation of heart tissue due to typhoid fever is a better term) should also get a code in case the doctor doesn't yet know whether the myocardium or endocardium is affected, so she can still assign a disease code to the patient prior to having full knowledge.

These three diagnoses are at different levels of precision: typhoid endocarditis is a more precise diagnosis, and typhoid fever with heart involvement is a less precise diagnosis. It is the nature of medicine that as doctors gather more information through interviewing, examining, testing, and assessing the response of a patient to treatment or watchful waiting, they are able to improve the precision of their diagnosis.

For example, the doctor may diagnose pharyngitis and then, when she gets the results of a culture two days later, improve the precision of the diagnosis to Streptococcal pharyngitis (that is, if the culture grows a type of bacterium called Streptococcus. If the culture does not grow any bacteria, then the precision of her diagnosis does not change significantly).

Proponents of ICD-10-CM usually refer to increased precision of diagnoses as improved "specificity" or increased "detail". However, in the medical field, the word "specificity" has another, more-commonly used, mathematical meaning. So it is best to avoid its use altogether in this discussion.

We have already pointed out that much of the alleged, improved precision in ICD-10-CM is not improved diagnostic precision at all, but rather just combinations of diseases, their manifestations, and other information about the patient and their encounters with the healthcare system (as opposed to other information about disease itself). Thus, although ICD-10-CM has 290 codes for diabetes mellitus, these codes do not represent different types of diabetes mellitus at different levels of diagnostic precision.

Doctors should simply code each disease at the highest level of diagnostic precision possible at the time. As they acquire new information that improves that level of precision, they should update the disease code.

Doctors should NOT classify the disease according to complex rules and inclusion and exclusion criteria, then assign the code for that class of diseases. Especially when the particular classification of diseases--ICD-9-CM or ICD-10-CM--is not intended for helping doctors care for patients, but rather for helping researchers, policy makers, and insurance companies analyze patient data for other purposes.

Instead, those who need to classify disease for research, infectious disease surveillance, setting health care policy, improving health care quality, and so on, should take the disease codes that physicians assign (for the purposes of patient care) and classify those disease codes as they see fit for their unique purposes. We doubt that a single disease classification such as ICD-10-CM can meet all those so-called secondary uses of data, anyway.

Allowing physicians and other providers to code each disease individually has the following benefits:

1. Health care providers (hospitals, doctors, etc.) never have to change coding systems, they will always use the individual disease coding system.

2. Those entities who need to organize patient data by classes of disease can organize diseases into whatever classes they need. If they need new classes of disease, they can simply re-organize the disease codes into new classes as needed.

3. No one will need to propose or be burdened by expensive, complicated, far-reaching upgrades to a one-size-fits-all, complicated, poorly designed, and technically obsolete diagnosis classification.

ICD-10-CM and the Physician's Superbill

2008-10-21T12:37:00.000-04:00

No, a superbill is not a bill that includes extravagant costs for a lousy bedside manner. Nor is it a proposed law in Congress that has merit.

A superbill is a form (usually on paper) that a physician uses at the end of every visit to mark all the billing codes she feels apply to that visit. Thus, for the numerous physicians who use a superbill, it is the link between clinical care and reimbursement.

A superbill typically contains a small subset of Current Procedural Terminology (CPT) codes and ICD-9-CM codes: usually those codes for which the physician bills most frequently. Without going into too much detail, the CPT code bills for the services the physician provided at the visit. The most typical codes are the so-called "evaluation and management" or E&M codes. In essence, the more complicated (and thus usually the longer) the visit, the more the physician gets paid.

The superbill also contains a small subset of ICD-9-CM codes to allow the physician to "check off" easily the diagnosis codes relevant to that visit. Thus, given that the most common chronic conditions that result in visits to primary-care physicians are hypertension, arthritis, diabetes mellitus, and depression, your PCP's superbill (assuming she uses one) has the ICD-9-CM codes for these diagnoses (as well as others).

In fact, your PCP's superbill may be derived from a superbill template (warning: pdf) produced by the American Academy of Family Physicians.

So, how will the switch to ICD-10-CM affect the superbill?

Well, the American Academy of Professional Coders (AAPC) recently issued a comparison between the ICD-9-CM superbill and what its ICD-10-CM equivalent would look like. The ICD-10-CM superbill (pdf) is a whopping 9 pages long, as opposed to its ICD-9-CM counterpart (pdf), which is 2 pages long.

The main reason the ICD-10-CM superbill is so long is the problem with combination codes we talked about in an earlier post. Now, instead of a single code for infectious mononucleosis, the superbill has 16 codes, mostly based on whether various complications are present (instead of just listing the complications by themselves with their own codes). Rheumatoid arthritis explodes from one code to approximately 90 codes: from one line to one page!

ICD-10-CM in this respect is worse than ICD-9-CM.

ICD-10-CM and Word Processing

2008-09-15T07:39:00.000-04:00

We noted in one of our first posts that the National Center for Health Statistics releases ICD-10-CM as a 23 MB portable document format document (click here to view it). And we noted that ICD-10-CM therefore fails to meet a fundamental requirement for a modern diagnosis coding system, namely that we can use it in our computer systems directly (which would require at the very least some machine-processable text file such as comma-separated value or tab-delimited text, instead of a file format meant for humans to read or print).

We have learned that in fact, the NCHS uses a word processor to create and maintain ICD-10-CM. The following quote is from a presentation that Dr. Chris Chute gave as part of a seminar series of the National Center for Biomedical Ontology:

...the American 10 clinical modification will migrate to the tools that we're using to build ICD-11, benefiting from a better environment. They're using a word processor now...kind of pathetic actually...

We agree, that is pathetic. To hear it yourself, go to a point approximately 32 minutes into the presentation and listen from there.

So, if modern tools exist now for creation and ongoing maintenance of the next version of ICD, why is NCHS still using a word processor?

Dr. Chute does go on to say that NCHS will migrate to these tools and ICD-10-CM will "evolve to become identical to ICD-11". But not until after 2015, when ICD-11 is finalized.

So, for the next 7 years at least, NCHS will continue to maintain ICD-10-CM with a word processor, and release it as a giant text blob from which one cannot automatically and reliably extract the set of codes it contains for use in a database or spreadsheet.

Thus, we have additional evidence that ICD-10-CM is based on archaic practices and technology. And $11 billion or more to upgrade to something archaic is a waste of money.

An Even More Costly Prerequisite

2008-09-11T21:15:00.000-04:00

In our last post, we mentioned that a standard called 5010 must be in place before ICD-10-CM. The reason is that 5010 replaces a standard that cannot accommodate ICD-10-CM.

5010 is a standard for submitting health care insurance claims.

First, a word about health care insurance. If you have health insurance and receive care from a doctor and/or a hospital, they submit a claim on your behalf to your insurance company. The insurance company pays the doctor and/or hospital directly for the services they provided. You are spared the hassle of receiving a bill, submitting a claim to the insurance company yourself, receiving the check in the mail, then sending it to the doctor and/or hospital to pay the bill. The doctor and hospital benefit as well, since they receive their payment in a more direct, timely, and reliable manner.

This description simplifies things quite a bit. But it and the fact that doctors and hospitals must put billing diagnoses on the claim form is sufficient to explain the need for 5010.

The whole process is even more efficient if doctors and hospitals submit claims electronically from their computer to the insurance company's computer. Because there are over 100,000 physician practices and hundreds of insurance companies--all of whom use computer systems from hundreds of software companies, the process of submitting claims electronically is made even simpler if all these entities use a standard electronic claim form. Any doctor or hospital using any standard-compliant computer system can submit a claim to any insurance company also using a standard-compliant system.

Today, this standard is 4010A. A law passed by the U.S. Congress in 1996 (called the Health Insurance Portability and Accountability Act) gave the Department of Health and Human Services (HHS) the power to mandate that all claims submitted electronically by organizations "covered" by this law (and nearly every doctor and hospital is "covered") use this standard. And HHS did so. And the health care system had to comply.

All told, implementation of 4010A cost the health care industry an estimated $28 billion. Yes, billion with a 'b'. And that's not our estimate, it's the estimate of HHS. Who has a bias towards underestimating the impact of their regulations on the industry so they can keep imposing more regulations. In their impact analysis on the rule to adopt 4010, HHS states: ...Although we cannot determine the specific economic impact of the standards being proposed in this rule
(and individually each standard may not have a significant impact), the overall impact analysis makes clear that, collectively, all the standards will have a significant impact of over $100 million on the economy. $100 million?

Well, 5010 is an 'upgrade' to 4010A. And to use ICD-10-CM as a coding system for billing diagnoses on claim forms, it is a requirement to upgrade to 5010.

Why can't we use ICD-10-CM codes on 4010A?

Because the 4010A form has a limited-length field for diagnosis codes. It limits the length of diagnosis codes to a maximum of 5 digits (warning: pdf, and see page 10 for the limit), the maximum length of an ICD-9-CM code. Why didn't the designers of 4010A allow for longer field lengths, knowing that HHS and others were anticipating an upgrade to ICD-9-CM? We don't know.

However, the maximum length of an ICD-10-CM code is 7 digits. So, there must be a change to the standard electronic claims form or we can't use ICD-10-CM. And that change is 5010, which fixes a number of deficiencies of 4010 in addition to the limit on diagnosis codes.

Which finally brings us to the cost. How much will it cost the industry to upgrade from 4010A to 5010?

By HHS' own estimate in the Notice of Proposed Rulemaking (NPRM) for 5010 (a different NPRM from the one mandating the upgrade to ICD-10-CM), it will cost anywhere from $5.6 to $11.2 billion (yes, with a 'b' again).

Here is a breakdown of the costs to the industry of adopting 4010A and HHS' estimates of the costs for upgrading to 5010 (numbers represent millions of dollars):

Type of organization	Cost to implement 4010A	Low 5010 estimate	High 5010 estimate
Hospitals	4,661	932	1,864
Physicians	2,175	435	870
Dentists	1,493	299	598
Pharmacy	336	95*	183*
Private plans	18,021	3,604	7,209
Gov’t plans	1,202	252	481
Clearinghouses	125	37	45
TOTAL	28,013	5,654	11,250

*Includes conversion to 5010 and another standard called D.0

We agree that it is reasonable to conclude that, because 4010A was the first time the industry implemented a standard electronic claims form, the cost of an upgrade to 5010 will be lower than the costs of adopting 4010A in the first place.

However, is it reasonable to assume a 60-80% reduction in costs?

Well, the Blue Cross and Blue Shield Association has identified approximately 850 complex changes that 5010 makes to 4010A. They also note (warning: ppt) that 5010 is a suite of standards for nine types of electronic claims transactions, and that a 5010 implementation guide for just one of the nine transactions is 700 pages long, with at least one modification made on every single page.

A reasonable estimate for a more modest, first upgrade is probably a 50% reduction.

But a 60-80% reduction for an aggressive, complex upgrade? We don't think so.

The update to 5010 will most likely cost the industry well over $10 billion. Even if the cost of an electronic medical record (EMR) were $100,000 per physician, $10 billion is enough to equip 100,000 physicians with one.

Thus, the prerequisite to ICD-10-CM is over $10 billion and ICD-10-CM itself will cost approximately $1 billion or more to implement, for a total of >=$11 billion to upgrade our diagnosis coding system in the United States.

If we're going to spend that much money upgrading our diagnosis coding system, shouldn't it be state of the art?

HHS Ignores Advice It Asked For

2008-09-08T20:44:00.000-04:00

In the Notice of Proposed Rulemaking or NPRM (warning: pdf) to mandate a switch to ICD-10-CM from ICD-9-CM for classifying diagnoses, the Department of Health and Human Services (HHS) mentions, on page number 49802 (the rule is in the Federal Register), that the Workgroup on Electronic Data Interchange (WEDI) sent the Secretary of HHS a letter on May 31, 2006.

The mention of this letter is significant because:

1. HHS is required by law to consult with WEDI on adoption of new code sets.
2. WEDI held a forum in April of 2006 to determine when and how to adopt ICD-10-CM.
3. The rule makes no mention of the recommendations of this letter.
4. The rule makes recommendations that directly conflict with the recommendations in the letter.

Perhaps Congress requires HHS to consult with WEDI because it recognizes that bureaucrats are wont to run roughshod over industry. If so, the NPRM is a good example of just such bureaucratic tendencies.

The official letter that WEDI sent to the Secretary of HHS is not available publicly: one must have a login to the WEDI web site to access it. Nevertheless, there are two publicly available documents that summarize the recommendations:

1. Co-Chair Report on ICD-10 Forum Discussion (warning: pdf)
2. WEDI ICD 10 Forum Recommendation to HHS Final Draft (warning: pdf)

We don't know if the latter truly represents the version that WEDI sent to the Secretary. For one thing, it does not even have a date.

However, the key recommendations from both documents are the same, and they are clear.

One recommendation that HHS blatantly ignores in its NPRM (it does not even mention the recommendation, let alone try to rebut it), is that implementation of another standard--known as 5010--should occur first. The NPRM requires that the industry adopt 5010 and ICD-10-CM concurrently, but that 5010 is required by April 1, 2010 and ICD-10-CM is not required until October 1, 2011.

Now it may seem that 5010 precedes ICD-10-CM. However, to meet those deadlines, the industry will have to start working on both standards now, and thus work on them concurrently.

The WEDI recommendation clearly states: This upgrade [to 5010] is too significant to be done in conjunction with ICD-10-CM and ICD-10-PCS conversion.

No wonder HHS doesn't mention this recommendation in the NPRM. It is too inconvenient. And it is too compelling to confront directly.

In a story about the effect of implementing 5010, the Blue Cross and Blue Shield Association notes that 5010 makes 850 complex changes to its predecessor standard.

Also, in 2007 WEDI and the North Carolina Healthcare Information and Communications Alliance (NCHICA) developed a detailed project plan that outlines all the steps the industry must take and milestones it must meet to adopt 5010. They derived a date of 2014 for final implementation of 5010 without ICD-10.

Yet HHS wants to adopt 5010 and ICD-10-CM by 2011?

WEDI is holding a policy advisory group forum from September 9-11 (just after this post) to address the ramifications of the NPRM on 5010 and ICD-10-CM. Let's hope they take HHS to task for ignoring the advice they gave it--advice that HHS by law is required to take into account.

Do We Need 290 Codes for Diabetes Mellitus?

2008-09-05T22:07:00.000-04:00

Despite the emerging genomics revolution that promises to identify the genetic and molecular basis of disease with unprecedented precision, the state-of-the-art science on the nature of diabetes mellitus has identified fewer than 50 subtypes of diabetes mellitus (for example, see the paper Diagnosis and Classification of Diabetes Mellitus).

Nevertheless, ICD-10-CM has approximately 290 codes for diabetes mellitus, not counting diabetes mellitus that arises during the course of pregnancy (also known as gestational diabetes mellitus). We say approximately because again, ICD-10-CM comes as a text document in a pdf. We counted twice and got 289 codes the first time, and 291 codes the second time. These codes span a full 21 pages of the ICD-10-CM document.

So, if we know there aren't 290 types of diabetes mellitus, how does ICD-10-CM derive 290 codes for it?

Combination codes.

A combination code is a code that allows the medical records coder (an entire profession has evolved to review the medical record, apply the rules for assigning billing codes, and create the final set of billing codes submitted to the third-party payer for payment) to assign several diagnoses (or, more properly classes of diagnoses) to a patient in one fell swoop. In addition, it helps to avoid the problem of choosing one diagnosis category as the "primary diagnosis". The coder may assign a combination code as the primary diagnosis, and voila, multiple diagnosis categories are all at once the primary diagnosis, with no messy decisions about which one was the most important or proximate cause of the medical care provided to the patient.

Here is an example of the combination codes created under the heading of diabetes mellitus (click on image to see the whole thing):

Code E11.321 is a combination of two diagnoses, a level of severity, and a physical manifestation of one of the diagnoses: type 2 diabetes mellitus, nonproliferative diabetic retinopathy, mild, and macular edema, respectively. All the possible combinations of types of diabetic retinopathy, severity, and presence/absence of macular edema are present under E11.3 Type 2 diabetes mellitus with ophthalmic complications.

Now, suppose you are a researcher who studies diabetic retinopathy to develop new treatments for this disease, which is the leading cause of blindness in the United States. Suppose further that for a particular study, you were interested in finding all the patients in your data set with nonproliferative diabetic retinopathy.

Instead of searching for all patients with just a single code that represents nonproliferative diabetic retinopathy, you have to locate in the ICD-10-CM pdf all the ICD-10-CM codes that include nonproliferative diabetic retinopathy. Then, you must search on all the codes you locate in this manner.

Nonproliferative diabetic retinopathy is combined with other diagnoses in approximately 50 ICD-10-CM codes. If you miss one, you'll fail to find patients who are potentially eligible for your research study. And since ICD-10-CM is a giant text blob, you cannot rely on the computer to find all 50 codes automatically for you. You have to search the pdf manually.

Combination codes make it hard to use ICD-10-CM encoded data for epidemiology, clinical research, decision support, and any number of other so-called "secondary" uses of medical records data (called secondary uses because the primary use is for the actual care of the patient).

Wouldn't it be better to have one code for one diagnosis? And to assign as many codes as the patient has diagnoses?

Is ICD-10-CM really a Diagnosis Coding System?

2008-09-01T07:55:00.000-04:00

The answer, perhaps surprising, is no, it is not. ICD-10-CM, like its predecessor, ICD-9-CM, provides codes for categories or classes of diagnoses, but not individual diagnoses.

For example, on page 3 of the 23MB pdf (warning: pdf) that represents ICD-10-CM in its official release format, we find A01.02 Typhoid fever with heart involvement. In the class represented by this code, the file lists two diagnoses:
1. Typhoid endocarditis
2. Typhoid myocarditis

The two diagnoses of typhoid endocarditis and typhoid myocarditis do NOT have their own code in ICD-10-CM. The code A01.02 represents a class of diagnoses, into which at least two diagnoses fall that have no code themselves.

Thus, we see that ICD-10-CM, true to its name, is a classification system. It does not purport to provide codes for individual diagnoses.

A more extreme example is G40.3 Generalized idiopathic epilepsy and epileptic syndromes. Here is a snapshot taken from the ICD-10-CM pdf:

Thus, G40.3 is a class of diagnoses that contains no fewer than 13 individual diagnoses.

Because ICD-10-CM tries to provide a class for every possible diagnosis, present or future, it creates a partition of the diagnosis space. As a result, it requires complex inclusion and exclusion criteria to determine which class or “pigeonhole” each diagnosis falls. These criteria often make it difficult to assign the correct code to a particular patient.

For example, C49 Malignant neoplasm of other connective and soft tissue—and its 15 subclasses—all have the following list of inclusion and exclusion criteria, which span the page break:

Note that, like the rest of ICD-10-CM, none of these inclusion and exclusion criteria are available in a format we can import into a database. Thus, before we can write programs that manipulate these criteria to ensure correct coding, we have to manually type them into our database tables, an error-prone and time-consuming process.

Because of the complexity of assigning a diagnosis to the correct ICD-9-CM category (a situation not ameliorated by ICD-10-CM), the accuracy of data coded with ICD-9-CM suffers. For example, one study found that up to 15-20% of patients classified as having acute stroke did not in fact have a stroke.

Another artifact of the partitional nature of ICD-9-CM and ICD-10-CM is that they both contain wastebasket categories, into which ‘everything else’ under a particular heading goes. For example,

The problem with these types of classes is that their semantics changes over time.

A real-world example of such a change occurred in ICD-9-CM with respect to coding of viral hepatitis. The following chart shows a decline in the incidence of Hepatitis, unspecified beginning about 1981 (open image in a new window to see it more clearly).

This decline was co-incident with the introduction of a code for the class of diagnoses of Hepatitis, Non-A, Non-B. Thus, the true incidence of diseases classified as Hepatitis, unspecified did not change. Rather, the definition of the class itself changed.

These types of wastebasket categories wreak havoc with accurate disease statistics over time. The history of ICD-9-CM is that important diseases such as AIDS and Hepatitis C initially get captured by wastebasket categories, then receive their own codes as they are defined by medical science. The statistics of the incidence and prevalence of these diseases subsequently become quite distorted and difficult to manage.

Yet another problem with ICD-10-CM classes or categories is that they often have criteria that have nothing to with diagnoses or disease, but instead to the timing and nature of the treatment of disease. For example, under the class M48.4 Fatigue fracture of vertebra, we find a requirement to add a 7th character to the code based on (1) whether it is the patient’s first visit to the health care system for such fractures, or a subsequent visit; (2) the rapidity with which the fractures have healed; and (3) whether any complications of such fractures are present:

Wouldn’t it be simpler to switch to a diagnosis coding system where each diagnosis receives its own code?

The Great Cost Debate

2008-08-30T08:44:00.000-04:00

The cost of the switch to ICD-10-CM (and its counterpart ICD-10 Procedure Coding System or ICD-10-PCS) is a subject of vigorous debate.

Prior to the proposed rule for mandating the switch, there were two studies that looked at the cost (RAND and Nolan) and a third analysis that examined the two studies (Hay). The proposed rule performs a detailed impact analysis of the costs and benefits of the switch (including drawing on both of the two prior studies), devoting 100 of 162 pages to it. This impact analysis examines all three of the prior analyses.

The first study (warning: pdf) was performed by RAND. The National Committee on Vital and Health Statistics commissioned RAND to perform this study.

Per the authors of the study, their charge was solely to evaluate the costs and benefits of switching to ICD-10-CM for diagnoses and to ICD-10-PCS for procedures: …we are asking not whether ICD-10 is the best coding system to switch to…

The RAND report states …our best guess is that the cost of conversion will run $425 million to $1,150 million in one-time costs plus somewhere between $5 million and $40 million a year in lost productivity.

The RAND report estimates the benefits of switching to be in the range of $700 million to $7.7 billion.

However, the estimate of benefits comes with a key assumption the authors admit does not hold today with ICD-9-CM: However, to realize those benefits, providers must use the full codes, use them correctly, and use them in a fashion that is neutral to the reimbursement system. ICD-9-CM is by no means always completely, correctly, or neutrally exploited.

Thus in the worst-case scenario, RAND estimates a net loss of $450 million, and in the best-case scenario, RAND estimates a net benefit of $7.275 billion.

The second study (warning: pdf) was performed by the Robert E. Nolan Company. The Nolan report, as it is known, only studied the costs of the switch and did not estimate benefits. The Blue Cross and Blue Shield Association commissioned the Nolan report.

The Nolan report states …Our estimate concludes that key segments of the health care industry would incur significant expenditure of between $6 to nearly $14 billion during a two- to three-year implementation period.

However, it did not consider costs that would be incurred by some significant segments of the health care industry, including nursing homes, clinical labs, durable medical equipment vendors, and several types of payer organizations such as third-party administrators, clearinghouses, and many small-to-medium-sized insurers.

Nolan also compared the switch to other recent, major upheavals in health care information technology: Y2K and compliance with the Health Insurance Portability and Accountability Act (HIPAA). The American Hospital Association estimated that Y2K cost hospitals alone $8 billion, as cited in Nolan. Although fewer information systems manage ICD codes than dates, and although systems that do manage ICD codes have fewer ICD fields in the database than date fields, ICD code sets are much more complex to convert and test. Furthermore, the $8 billion affected hospitals alone, not physicians, payers, and so on.

The Hay report summarized RAND and Nolan to derive yet a third estimate of the costs of the switch. America's Health Insurance Plans commissioned the Hay report.

The Hay report concludes that A reasonable preliminary estimate of the total cost to the healthcare system would be $3.2 to $8.3 billion.

Finally, we come to the proposed rule, which takes all three analyses and comes up with yet a fourth estimate, which we described in our last post: $849 million to $3 billion with a “primary estimate” of $1.64 billion.

The proposed rule also estimates benefits, and under its more optimistic estimate of costs (relative to Nolan and Hay), even it does not see any benefit accruing to the health care system until 2018 (that is, it estimates that the net cumulative benefit will not exceed the net cumulative cost until 2018, 7 years after the switch takes place).

This table summarizes the reports and their cost estimates (in millions of dollars):

	RAND	Nolan	Hay	NPRM
Low	425	5,700	3,200	849
High	1,150	13,900	8,300	3,000
Primary estimate				1,640

Regardless of the strengths and weaknesses of any of these given estimates, the fact is that the estimates vary wildly, and they are just that, estimates. No one has a reliable prediction that can be trusted to within plus or minus a few hundred million dollars. The cost of switching is high.

To put these estimates in perspective, the health care industry spent $1.1 billion on electronic health records (EHRs) in 2005, with a projected growth to $4.8 billion by 2015. Given limited resources, will the ICD-10 switch impede EHR adoption, just as Y2K and HIPAA did?

HHS proposes rule to require ICD-10-CM by 2011

2008-08-19T20:23:00.000-04:00

On Friday, August 15, the Department of Health and Human Services issued a notice of proposed rule making that would require the adoption of ICD-10-CM for the purposes of diagnosis coding. They proposed a date of October 1, 2011 for the switch.

The proposed rule is available here (warning: pdf).

The proposal recommends an "all at once" change over. There would be no phased approach, or time period where both ICD-9-CM and ICD-10-CM are used concurrently.

The proposed rule would affect all "covered entities" under the Health Insurance Portability and Accountability Act. Determining whether a health care provider, physician, insurance plan, or claims "clearinghouse" is a covered entity is a bit complex (see the 10pp pdf file the Centers for Medicare and Medicaid Services provide for making the determination). However, the bottom line is that the vast majority of physicians, physician practices, hospitals, health plans, and claims clearinghouses are covered and thus affected.

A great deal of the proposal is made up of a detailed analysis of the costs and benefits of the switch. The proposal itself does not provide a total cost, but one can easily add up the costs in Table 10. The cost estimate ranges from $849 million to $3 billion, with a "primary estimate" of $1.64 billion.

We'll have a lot to say about various myths that people cite in favor of a switch to ICD-10-CM in coming posts. However, suffice it to say that many of these myths are reproduced in this proposal as arguments in favor of ICD-10-CM. We'll expose these myths.

All in all, the notice of proposed rule making is a colossal mistake. Again, if we will expend billions of dollars to change our diagnosis coding system, we ought to switch to a better system than ICD-10-CM.

What is this all about, anyway?

2008-08-17T20:16:00.000-04:00

The coding of diagnoses by the health care system initially supported the goals of education and quality improvement (Dr. Slee, whom we mentioned in yesterday's post, was an early pioneer in health care quality improvement efforts).

However, in 1983 the government stepped in and changed that situation radically. It implemented a prospective payment system within the Medicare program. This system uses diagnosis-related groups (for hospital billing), which in turn are based on ICD-9-CM codes (at least for now).

Thus, all health care providers (physicians, hospitals, etc.) who accepted Medicare as payment for services (nearly all of them) were thus required to submit ICD-9-CM codes for the diagnoses that were relevant to a patient visit or hospital stay. If they wanted to get paid, that is.

Thus, beginning in 1983 ICD-9-CM took on the role of supporting billing, or "administrative" purposes (a euphemism for billing and payment) at the national level.

Because most health insurance companies mimic the programs and projects of Medicare, most of them followed suit. Thus, providers were required to submit ICD-9-CM codes to all third-party payers, not just Medicare.

The net result is that a change in the system for coding diagnoses has huge ramifications that impact nearly every physician, hospital, nursing home, and so on in the United States. And patient. How your diagnoses are encoded affect you, too.

In future posts, we will look at studies of the costs of changing the diagnosis coding system. We will also look at uses of "administrative" data that were never imagined prior to the implementation of DRGs in Medicare. We'll explain how diagnosis coding affects you. And we'll spell out the dysfunction current in the system, and why ICD-10-CM will not address most of it.

The Tyranny of the Diagnosis Code

2008-08-16T08:52:00.000-04:00

Dr. Vergil Slee and associates nicely summarize the core problems with ICD-9-CM and ICD-10-CM, and why the upgrade to ICD-10-CM is only a marginal improvement:

Slee VN, Slee D, and Schmidt HJ. The Tyranny of the Diagnosis Code. North Carolina Medical Journal, 2005;66(5):331-7.

Lest you think that this paper is unimportant, no less an authority than Dr. David Kibbe gave his approval in a commentary published in the same issue as Slee et al.'s paper (available via the same link above).

Dr. Kibbe is Director, Center for Health Information Technology of the venerable American Academy of Family Physicians (AAFP). The AAFP is the premier specialty society for family physicians in the United States, and represents 95,000 physicians.

Dr. Kibbe also shudders at the thought of using ICD-9-CM and ICD-10-CM as the foundation of the information we use to improve the quality of health care in America.

However, he stops short of endorsing a course of action to adopt an alternative to diagnosis coding that is vastly improved over ICD-9-CM and ICD-10-CM, citing a lack of political and "economic" will in America to do so.

That's a shame. The opposition of the AAFP to ICD-10-CM might have helped reverse that situation.

And if you are wondering what authority Dr. Slee may have to comment on these matters, the following is a brief biography, taken from additional commentary he made with a colleague to the House Ways and Means Committee on the issue of the switch to ICD-10-CM:

Vergil Slee, MD, MPH, FACP, FACHE (Hon) was responsible for the first deployment of ICD in hospitals as a tool for diagnosis indexing, a task for which ICD was admirably suited at that time (1955). In 1975 he represented the U. S. at the WHO conference which designed ICD-9. In 1976 he became President of the Council on Clinical Classifications which, in collaboration with the U. S. National Center for Health Statistics, developed ICD-9-CM (1978). He has analyzed ICD-10-CM (Reference 6) and has written extensively on the expanding demands on medical record information (Reference 7), demands which have destroyed ICD’s suitability for diagnosis input.

A fundamental requirement

2008-08-11T21:16:00.000-04:00

If we're going to have a database of health care data, then the codes we use to refer to diseases ought to be in a form that we can import into a database.

In other words, we require a file that associates each code with a disease in a way that the computer can reliably extract and work with the codes.

For example, a common, machine-readable file is a comma- or tab-delimited file:

12345,Coronary artery disease
23456,Diabetes mellitus
34567,Asthma

However, neither ICD-9-CM nor ICD-10-CM are available in such a format. In fact, both disease classifications are released in a file format that makes it impossible to import codes directly into database tables.

The National Center for Health Statistics—which maintains the disease classifications in ICD-9-CM (it also includes a classification of procedures, which is a long story for another post) and ICD-10-CM—releases ICD-9-CM in a rich text file format. It releases ICD-10-CM in portable document format (pdf).

Here is a portion of ICD-10-CM from its 2,392 page, 23MB pdf file:

The net implication is that you cannot get ICD-9-CM or ICD-10-CM, from its source, in a format that you can import into a database table.

Thus, neither ICD-9-CM nor ICD-10-CM meet the most basic requirement for moving health care information into the modern era: we need disease codes in a format for use in computers, not for printing!

The purpose of this blog

2008-08-04T17:00:00.000-04:00

The sole purpose of this blog is to advocate for a better alternative to diagnosis coding than ICD-10-CM (the International Classification of Diseases, Tenth Revision, Clinical Modification). The United States government, in particular the Centers for Medicare and Medicaid Services (CMS), is considering whether to 'switch' from coding with ICD-9-CM to ICD-10-CM. At present, CMS requires that all health care providers (hospitals, physicians, etc) who bill Medicare or Medicaid for services rendered, encode the diagnosis or diagnoses necessitating those services with ICD-9-CM.

The essence of our argument against the change is that ICD-10-CM, despite superficial improvements over ICD-9-CM, is not a sufficient advance to warrant the cost. The basic structure of ICD-10-CM is the same as that of ICD-9-CM, which was created in the era of punch cards and batch jobs. The science of medical terminology and ontology has advanced so far beyond the structure and content of ICD-9-CM and ICD-10-CM, that 'upgrading' to ICD-10-CM will preserve the Dark Ages of healthcare information.

Over the coming months, we will present our arguments against the upgrade to ICD-10-CM and in favor of a better alternative. Stay tuned.