Why does ICD-10 feel so bad?

It has been freezing cold in much of the country for the last two months, but things have been heating up in the controversy over the implementation of ICD-10. First, a quick primer for those of you who have not been following this.

The “ICD” in ICD-10 stands for International Classification of Diseases. The “10” refers to the version of the taxonomy, which is maintained and revised periodically by the World Health Organization and “is the standard diagnostic tool for epidemiology, health management and clinical purposes.” Although conversion from the ICD-9 standard, which is still in use in the US, to ICD-10 is causing a major kerfuffle, it is important to note that ICD-10 has been around since 1990, and the WHO is poised to release ICD-11 in 2017. The 9th and 10th editions differ primarily in their specificity of coding, with the 10th differentiating between acute and chronic states of the same condition, left and right sided findings, initial and ongoing treatment, etc. The net result, of course, is that there are a lot more ICD-10 than ICD-9 codes to describe the full array of human disease and unfortunate mishaps, even though humans and the things that befall them have not gotten much more complicated since 1990.

The current controversy arises from the fact that the Centers for Medicare and Medicaid Services (CMS) has mandated that hospitals and physicians submit their bills using the new codes as of October 1, 2014, effectively creating a new national standard for reimbursement determinations. The timing of the change-over means that doctors and hospitals must implement this as they simultaneously struggle with new quality mandates and IT meaningful use requirements. No wonder, then that the AMA has renewed its call for a delay in implementation, citing, among other things, a study (that it funded) that estimates that it will be financially “disastrous” for physicians to implement ICD-10.

Although these are legitimate concerns, I think the objections that many physicians have to ICD-10 goes deeper than having to change some old habits of how we write our notes and drop our bills. I think it has to do with a fundamental disconnect about the role of “documentation.”

As students and trainees, we were taught that the medical record is a tool for patient care. That it is intended to share information with other providers; or create a narrative over time, so that a patient’s progress (or lack thereof) can be observed; or provide a repository of reference information that may serve a future, as yet unidentified, clinical need. Yes, including enough information in our records for others to summarize into ICD-10 codes based on hospital documentation, or selecting the codes ourselves for office-based encounters, serves those ends. But the problem is that most clinicians believe that they can achieve the fundamental goals of clinical documentation without the constraints and complexity of ICD-10 coding.

Here is the real problem. Just as I pointed out with EMRs, we have accepted a system that pays doctors and hospitals for “doing stuff.” Naturally, those paying the bills want to make sure that the stuff they are paying for is both appropriate and actually getting done, and have demanded that we “document” both. The language chosen for that exchange (we tell you what we did, and you pay for it) is an epidemiologic classification scheme that was not designed for that purpose. Is it any wonder that doctors hate it?

Despite the disconnect, ICD-10 is coming and North Shore-LIJ is moving forward with its ICD-10 education. See HealthPort for details.

In the meantime…What do you think?

5 thoughts on “Why does ICD-10 feel so bad?

  1. Thank you for summarizing the most current “Angst” causing concern among practicing physicians.
    I think you got it when you said that we have to “Do stuff” to get paid. It is an incredible disconnect when you hear about how we should be moving away from “Doing stuff”, as in Fee for service to a more Accountable model, as in ACOs etc. ANd yet we are asked to “Document” in greater detail; to satisfy ICD 10.
    As Director of ICD 10 Education for NSLIJ Health System, I have been exposed to this dileema in some detail. Medical Group Physicians are reimbursed by RVUs and yet they are being asked to evolve into accountable physicians.
    ICD 10 at an academic level makes perfect sense. The detail it demands already exists in a well written note. It is not any new medicine or trickery. The problem lies in the constraints we all operate under. If you are an employed physiicna, then at least you dont have to worry about the day to day administartive stuff. As a voluntary doc, It is all up to me! Who has time for details.
    Technically, why do we even need codes. Computers are certainly far advanced now. Google and NSA can index every corner of the internet to serve their respective puposes.
    I can only hope for a world where a Doctors well written note with Medically appropriate terms is enought to show what we did for our patients.
    Until then, we are at the mercy of various vendors who know how to expoit our plight.
    Thanks
    Inderpal Chhabra MBBS FACP

    1. I would like to bring to your attention that we’ve developed and recently released a web / mobile app that will help both coders and physicians with the ICD10 transition.

      The advantages / differentiators of ICD10Doc:
      Search with multiple and partial terms
      More search terms will return a smaller results set
      Procedures (ICD-10 PCS) coding is now available
      Reverse search for both diagnosis and procedures
      Nothing to download or install
      Works in all browsers, on desktops, tablets and mobile phones
      No login required
      No advertisements
      FREE of charge for a limited time

      You can test drive it at http://ICD10Doc.com
      Looking forward to your feedback.

      Many thanks,
      ICD10Doc team

  2. Don’t love the commercial plug but appreciate the comments, which share the theme of “there must be a better way to do this” that leverages advances in information technology. For docs in their offices, “look-up” functionality is generally already built into their EMRs (if they have one). For docs writing notes on hospitalized patients, we are still stuck in the need for specific documentation to support increasingly specific codes. Until payment models change substantially or natural language processing of physician notes gets a lot better (into the realm of mind-reading) we are stuck with needing to know “the magic words” to get appropriate bills out the door to get paid for the work we do.

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