Who Really Benefits from the ICD-10 Transition?

With over 500,000 apps for the iPhone, there must be one that will do what you want. The slogan "There's an app for that" is pure marketing hype. Some apps meet your requirements and expectations exactly and some come close but often you're out of luck - sheer numbers alone don't guarantee anything.

There are many reasons why there may NOT be an app for that: maybe Steve Jobs thought you should never be allowed to do the thing that you now want to do, maybe no developer has thought of it yet or views the need the same way you do, or maybe it costs so much you are not willing to experiment. With ICD-10 there are over 148,000 codes so you would think that there must be a "code for that" - one that fits the patient's problem. Again, no such luck. Sometimes there is a code that fits precisely, sometimes it's close and often there simply isn't any code that accurately describes your patient. The codes that are defined strike me as an odd assortment. Whose interests do they serve? Not yours. Not mine. Not the patient's. Maybe Medicare's? Read on and see what you think.

I mentioned the essential meaninglessness of codes last week. Meaningless or not, ICD-10 will be going into effect soon. Many are estimating that it is going to cost billions to make the change. My attention was drawn to this topic by a recent news report that described in detail the ICD-10 codes that are available to describe a patient that “walked into a lamppost” - one for the initial encounter, one for a subsequent encounter, and a third for sequelae. It turns out that there are similar sets of codes for walking into walls, furniture, and unspecified stationary objects.

Struck by the oddity of the selection and for no particular reason, I looked up “struck” and discovered all sorts of interesting options including struck by cow, struck by dolphin, struck by macaw, and struck by other sports footwear. This led me to discover a profusion of codes related to water craft, parachuting, bungee jumping, firearms, polo, and rock climbing. There are, however, no codes for being struck by a falling tree or by one's spouse. It's hard to imagine that these codes are going to provide Medicare with much additional information that will help them reign in healthcare costs.

This got me interested in how it would be to use ICD-10 in my practice. The diagnosis that I record most often is Latent Tuberculosis Infection (LTBI) as defined in the LTBI guidelines published in 2000 by the American Thoracic Society and Centers for Disease Control and Prevention. The LTBI patient has acquired a primary infection which presumably dispersed mycobacteria to various locations within the body which subsequently entered a dormant phase as a result of the body's immune responses. It is distinct from any overt disease caused by M. tuberculosis. The ICD-9 has a code for LTBI - 795.5 Tuberculosis, latent. ICD-10 does not, but it does have codes for accidental poisoning by PPD, Poisoning by PPD due to intentional self-harm and poisoning by PPD of undetermined intent. How nice. This is going to be a problem for me.

From a clinical perspective, it doesn't look like ICD-10 codes are going to be of any more use than the ICD-9s, maybe less. To whom might they be of interest? Possibly insurance companies, because even in the era of managed care, ACOs, and global payments, they still expect detailed coding. Since healthcare reform will cut the insurance companies off from one former source of profit - the ability to exclude people with pre-existing conditions, you can be sure the insurers will be searching for other ways to make a profit. Once ICD-10 goes into effect insurance companies will have access to detailed codes that identify genetic susceptibilities (there are codes for that too,) family histories of disease, and participation in hazardous pastimes if the coders are meticulous. When applying for life insurance, applicants are required to grant life insurance companies access to their entire medical history which in the future will reveal a wide variety of conditions that might affect insurability and premiums. I seem to recall that a number of large health insurers are also life insurers. So - if we follow the money - it is reasonable to expect that many people will be confronted by increased costs for life insurance as their pre-existing conditions and lifestyles begin to be reflected in ICD-10 coding generated as they receive healthcare. Hmmm.....

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