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.
Wednesday, December 17, 2008
Tuesday, November 18, 2008
Could ICD-10-CM reduce the primary care workforce?
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:
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”.
Sunday, November 16, 2008
Internists oppose the switch to ICD-10-CM, too
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:
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.
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).
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.
Saturday, November 15, 2008
Family physicians oppose switch to ICD-10-CM
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:
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!
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 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!
Wednesday, November 5, 2008
The blogosphere recognizes the pitfalls of ICD-10-CM
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:
The blogosphere isn't fooled. ICD-10-CM is a poorly designed and executed boondoggle.
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
The blogosphere isn't fooled. ICD-10-CM is a poorly designed and executed boondoggle.
Monday, October 27, 2008
Combination code explosion: An illustration
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:
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):
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
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
Friday, October 24, 2008
More On Diagnostic Precision
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.
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
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.
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.
Tuesday, October 21, 2008
ICD-10-CM and the Physician's Superbill
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.
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.
Monday, September 15, 2008
ICD-10-CM and Word Processing
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.
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.
Thursday, September 11, 2008
An Even More Costly Prerequisite
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):
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?
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?
Monday, September 8, 2008
HHS Ignores Advice It Asked For
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.
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.
Friday, September 5, 2008
Do We Need 290 Codes for Diabetes Mellitus?
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?
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?
Monday, September 1, 2008
Is ICD-10-CM really a Diagnosis Coding System?
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?
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:
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:
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,
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:
Saturday, August 30, 2008
The Great Cost Debate
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
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
The
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,
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):
| | | 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?
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