ICD-10 Red Tape 101

How would you go about describing ICD-10 and its shortcomings to the public?  Recently a student asked for an explanation of ICD-10 and Parth Desai of http://www.icd10charts.com/ provided a superb reply:

Hi Austin,

Great question! I’ll be brief with my explanation, but if you need any more information I’ll be happy to answer it a little more thoroughly after my last test for school is done next week.

ICD-10 CM is the new medical coding system that was implemented by the federal government on October 1, 2015. This coding system replaced the previously used ICD-9 system which was in place since around 1979. ICD-10 was a highly controversial system because of how large of an administrative burden it posed on medical practices, particularly for private practice physicians. It was so controversial in fact that ICD-10 was delayed 3 times over the last 10 years by Congress before it was finally enacted last year. Now before I go into the real issues with ICD-10, let me quickly explain how physicians get paid by insurance companies using these codes.

So when a patient goes to see their physician or pediatrician for a routine visit, the physician treats the patient and records all of the diagnoses that the patient is coming in with. Then the physician or the physician’s office staff has to “code” all of the illnesses that the patient is diagnosed with using the appropriate ICD-10 code. In order to get reimbursed for their work, the physician must submit this information to the patients insurance company in the form of a claim. For example, if I went to my doctor’s office with an acute sinus infection of my maxillary sinus, one of my ICD-10 codes on the claim might be “J01.00 Acute maxillary sinusitis unspecified.” For patients with multiple chronic illnesses, the claim may have many different highly specific ICD-10 codes. Then about 1 month later, if the physician did not make any mistakes with their ICD-10 codes on the insurance claim, the insurance company will pay the physician for the treating their patient. If however, the physician made a mistake reporting the ICD-10 codes, the insurance company can deny the claim and not pay the physician for their work on time. Then the physician or their office staff has to go through and make the appropriate correction to the ICD-10 codes on the insurance claim, then resubmit the claim, and wait as long as 3 more months before receiving payment for seeing the patient they treated several months ago.

The biggest difference between ICD-9 and ICD-10 is one of specificity. ICD-9 had roughly 14,000 possible diagnosis codes, while ICD-10 has about 68,000 potential diagnosis codes. This posed an issue to medical practices because it naturally takes more time to find the correct code when their are so many more possible codes to be used. To give you an idea of how almost comically specific ICD-10 is, here is a short list of some of the funnier codes that are built into the system:

W61.33 Pecked by a chicken
Y92.241 Hurt at the library
Y93.D1 Accident while knitting or crocheting
W56.22 Struck by orca, initial encounter
V91.07 Burn due to water-skis on fire

The other biggest issue with ICD-10 was the lack of resources to help physicians and medical practices prepare themselves for ICD-10. CMS and HHS (the two government organizations that led to ICD-10 being made a requirement) actively did the opposite of helping physicians by making the entire process of implementing ICD-10 into a very difficult and expensive transition. For example, instead of using simple file formats that any practice could download to access all of their ICD-10 codes, this process was instead made incredibly complex so that only those with IT backgrounds could effectively use the ICD-10 resources. So what ended up happening was medical practices had to spend thousands of dollars and hundreds of hours each to prepare for ICD-10. To give you an example of what this might be like, let’s say your school just passed a rule that implemented a new made-up language that every student had to speak if they wanted to eat food from the cafeteria. We’ll call it “Cafeteria” and say that any student that did not learn and use the knew language to order food, they could not eat cafeteria lunch. Now it would be one thing if the school provided a way for all of the students to learn how to speak “Cafeteria.” Everyone would be annoyed but it wouldn’t be the absolute worst thing. But what if instead of teaching the students the language, instead your school required each student to spend their own money and time learning to speak their new made-up language. On top of that let’s say the school also constantly put out literature trying to convince you and your classmates how easy of a language “Cafeteria” was to learn, but they still did not make any real effort helping the students learn the language. Essentially, that’s what happened with ICD-10, and a lot of physicians were very upset about it.

I hope this helps Austin and if you have any questions feel free to email me. Good luck and we’re all very impressed that you are getting interested in medicine at such a young age!

Parth Desai

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