Healthcare // Policy & Regulation
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3/27/2014
11:30 AM
David F Carr
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Easy-to-Mock ICD-10 Diagnosis Codes...

...and the logic behind them.
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Ah, those crazy ICD-10 codes. Ever since the Centers for Medicare and Medicaid Services got serious about pushing toward implementation of the new diagnostic coding system, one of the ways opponents of the change have fought back is with ridicule.

After delaying the implementation several times, CMS has now indicated it won't budge from an October 1 deadline for the new standard. What CMS is mandating is actually a US-specific variant of the ICD-10 code set ratified by the World Health Organization in the 1990s and already implemented in some form in most of the rest of the world. CMS has packed its version with all sorts of details that it, other payers, and public health officials would like to track.

With 68,000 codes, some very specific, the new code set is full of surprises. It even inspired an illustrated book, Struck by Orca, a reference to code W56.22XA, "struck by orca, initial encounter." There's also W56.22XD, "struck by orca, subsequent encounter," and W56.22XS, "struck by orca, sequela" (meaning some sequel or recurrence months or years after the original orca drama).

Through their website, ICD-10 Illustrated, the book's creators also offer posters and PowerPoint slides healthcare leaders can use to introduce their staffs to the hilarity that is ICD-10. You can see a couple of sample images from the catalogue above.

Defenders of ICD-10 say the mockery is misleading, however; that most people will never use the more obscure codes any more than they would use all the obscure words in the dictionary. In most cases, the examples people point to about the circumstances of freak accidents are not diagnosis codes at all, nor are they mandatory codes that must be included for billing. A concussion from being struck by an orca is not necessarily all that different from a concussion suffered playing football in terms of head trauma -- although there are legitimate public health reasons for tracking how many concussions are associated with playing football.

If you're wondering, W21.81XA is "striking against or struck by a football helmet, inital encounter" -- again, that's a circumstance, not a diagnosis. The diagnosis would be something like S06.0X1A, "concussion with loss of consciousness of 30 minutes or less, initial encounter."

The language about initial and subsequent encounters, which appears throughout ICD-10, is one of the things some people find comic. The common misunderstanding is that "struck by turtle, second encounter" must mean the patient keeps coming back to the office after being hit by yet another turtle, or the same turtle repeatedly. It actually just means the patient came back for a follow up visit.

That said, here is a quick tour through the dizzying world of ICD-10 codes.

David F. Carr oversees InformationWeek's coverage of government and healthcare IT. He previously led coverage of social business and education technologies and continues to contribute in those areas. He is the editor of Social Collaboration for Dummies (Wiley, Oct. 2013) and ... View Full Bio

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dwebb608
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dwebb608,
User Rank: Apprentice
4/8/2014 | 11:51:48 AM
Re: Optional ICD-10 codes?
"Optonal" codes depend on the circumstances.  It means one thing when reporting to a payor, and quite possibly another when reporting to various regulators.

For the Orca bite, for instance, the health department may want to differentiate between an Orca and an Alligator to track who's doing the chewing as a Public Safety measure, but the payor might be more concerned with which pieces the biter left behind and what repairs were necessary.
Alison_Diana
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Alison_Diana,
User Rank: Author
3/31/2014 | 11:33:43 AM
ICD-9 vs. ICD-10
In one example a CMS executive gave me, the new codes will impact patients and insurers in quite basic ways. Here's the scenario she gave me. Under ICD-9: In April, Johnny falls off a neighbor's tree, breaks his left arm, and goes to the hospital. Doctors fix him up and insurance pays. In May, Johnny falls off the same neighbor's tree, breaks his right artm, goes to the hospital, doctors fix him up -- but insurance balks, saying "We already paid for this." That's because ICD-9 doesn't specify right or left limb. Under ICD-10, the doctor has to state s/he is working on the left or right arm. The insurance company sees it's a different arm and paperwork goes through smoothly.

Of course, klutzy little Johnny who likes trespassing could ostensibly continue to break the same arm. But at least if he alternates arms it'll be easier for his parents to get the bills paid -- until they finally ground him or the neighbor gets a mean dog and/or a taller fence.
David F. Carr
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David F. Carr,
User Rank: Author
3/31/2014 | 9:04:18 AM
Re: How about some credit on image #1?
Nifty book. We linked to your website and to the page for the book itself, as well as mentioning the other resources you offer like PPT slides.
StruckbyOrca
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StruckbyOrca,
User Rank: Apprentice
3/30/2014 | 2:50:06 PM
How about some credit on image #1?
That's from our book of more than 35 illustrated ICD-10 codes: icd10illustrated.com
dentdavi
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dentdavi,
User Rank: Apprentice
3/28/2014 | 10:56:51 PM
Re: Optional ICD-10 codes?
The desire to code every possible problem, indcident, variation or occurence may be a bit over the top and obsessive. Additionally, coding systems will always fail to keep up with the times. Where are the "Shocked by the iPhone, subsequent occurence", and "Internet addiciton" codes? A better approach might be to create category codes rather than specific codes for every possible condition and provide spedifics defined in additional fields. e.g. Traumatic injury, mechanism - fell off ice yacht or impaled by falling flag pole (I have seen this one), associated injuries - femur fracture (can code for this),  or Laceration, mechanism - ran into mailbox, location - right forhead, depth - deep, length - 3.5 cm, etc.  
Ariella
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Ariella,
User Rank: Ninja
3/28/2014 | 9:15:19 AM
Re: Optional ICD-10 codes?
@Laurianne good point. It's a far cry from the keeping it simple imperative. No one can possibly keep all those in mind and will have to cnstantly refer to a reference source to be sure to be on the right side of the code.
Ariella
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Ariella,
User Rank: Ninja
3/28/2014 | 9:15:19 AM
Re: Optional ICD-10 codes?
@Laurianne good point. It's a far cry from the keeping it simple imperative. No one can possibly keep all those in mind and will have to cnstantly refer to a reference source to be sure to be on the right side of the code.
David F. Carr
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David F. Carr,
User Rank: Author
3/27/2014 | 5:03:18 PM
Re: Optional ICD-10 codes?
You certainly couldn't expect people to memorize 68,000 codes, or flip through a phonebook-sized directory to look up the right one. The burning question is how much of this process can be automated. For there to be 68,000 codes tracked in a database is not a bad thing, as long as the database application does most of the work. Providers will need to have a familiarity with the codes that occur most commonly for their specialties (which might not include orca bites). The EHR vendors are all competing to show how they can simplify the process of identifying the right code or set of codes for the right condition. Some will do a better job of pulling this off than others. Maybe even in the best case, it will still be a pain to adapt, but it doesn't necessarily have to be pure torture.

Also, remember that some of those 68,000 codes are elaborations on a base code, all those left/right, first encounter/subsequent encounter distinctions.
Laurianne
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Laurianne,
User Rank: Author
3/27/2014 | 4:42:39 PM
Re: Optional ICD-10 codes?
68,000 codes. This is the kind of detail that brings home how complex medical regulation has become. Doesn't this just not pass your common sense test?
David F. Carr
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David F. Carr,
User Rank: Author
3/27/2014 | 12:47:12 PM
In defense of medical documentation
The column linked below from ICD10monitor.com defends the new coding as good documentation, offering these comparisons:

Restaurants:

Imagine ordering a filet mignon (medium-rare), braised asparagus with hollandaise sauce, and a glass of Cabernet Sauvignon, Knights Valley, 2008. If the waiter documents "meat unspecified, vegetable with a sauce, and glass of unspecified wine," it is unlikely that any physician would pay the $90 bill listing these items.

Air Travel:

Imagine if you are on a plane and the pilot announces that "we will be flying to an unspecified location arriving at an unspecified time. By the way, I didn't do the flight check list because I hate cookbook flying."

- from ICD-10: The Burden of Documentation http://buff.ly/1mwP2ij

In other words, doctors and health IT folks should suck it up and make this work.
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