ICD-10 will accelerate the demise of private practice

You won’t read about the International Classification of Disease (ICD) on TMZ or hear it discussed on The View, but it has the potential to be an unpleasant October surprise in the healthcare world. It is a list of codes that physicians and hospitals use when billing insurance companies. These codes cover all manner of medical diagnoses for diseases, conditions, and injuries.

The first version of ICD appeared in 1946 with periodic revisions since. Six months from now, on October 1, the latest version, ICD-10 was supposed to be implemented in the US. We are late to the party, with other countries implementing this over the past 15 years.  ICD-10 has already been delayed for a year, but the administration promises no further delays. But similar to other promises, this may be another “never mind.” Congress voted for the 17th time to delay the April 1 SGR cuts, and attached a one year delay in ICD-10 implementation to their bill.

ICD-10 is not the fault of Obamacare nor is it Bush’s fault. Instead this classification even preceded Bill Clinton.  So this is not a partisan issue. Instead it is an issue of complexity, arriving in the wake of the largest healthcare overall in history with its attendant chaos and confusion. The current version, ICD-9 uses a 4 or 5 digit number to code for a particular disease, such as 540.9 for appendicitis. ICD-10 will have up to 7 alphanumeric characters to specify a condition such as S52.521A for “Torus fracture of lower end of right radius, initial encounter for closed fracture.” And there are now over five times as many codes for doctors and hospitals to choose from. But isn’t specificity better? Sure it is. Big data is the new frontier in medical research, making sense of the huge amount of generated healthcare data. But can this go to far?

In an effort to push specificity to the limit, some ICD-10 codes have gotten silly. Codes exist for being hurt at the opera (Y92253), walking into a lamppost (Y92253), walking into a second lamppost (W2202XD), getting sucked into a jet engine (V97.33XD), or being burned due to water skis on fire (V91.07XD). But this is not the Achilles’ heel of ICD-10.

First, medical practices and hospitals must know and have all of these 68,000 codes readily available to add to the medical record in order to bill correctly and hope to be paid. One more distraction for physicians, aside from all of the daily distractions of electronic records. When physicians pay more attention to their computer screen or tablet than to the patient, guess who suffers? This is the reason why texting and driving is illegal.

Second, electronic medical records (EMRs) must be able to incorporate these codes into the exam or procedure report. Are all EMR vendors up to speed on these codes? Will their system upgrades work as advertised? Or will they work as well as the Healthcare.gov website? And if the codes don’t work, physicians and their practices don’t get paid. Yet landlords, employees, and utility companies still want to be paid.

Third, will the insurance companies recognize each of these new 68,000 codes, correctly match them to billed procedures, and promptly pay the providers? If I treat a patient with macular degeneration with a monthly dose of a $2000 drug, I now bill a single code, which insures I will be paid. Under ICD-10, there will be 20 codes, specifying which eye(s) and severity, which allow payment. Will every insurance company have each of these codes in their computers? Will it recognize each code? Remember that these are the same insurance companies that don’t even know who has actually paid their insurance premiums.

The American Medical Association announced that ICD-10 implementation will cost three times as much as originally estimated. The  “costs of raining, vendor and software upgrades, testing and payment disruption” could be  $225,000 for a small medical practice and over $8 million for a large practice. How do medical practices of marginal profitability absorb these costs? With physician reimbursement rates set to grow at only 1/2 percent per year over the next five years, far below the true rate of inflation, of close to 10 percent, the financial writing is on the wall. This will accelerate the demise of private practice, already underway due to Obamacare. When ICD-10 is eventually implemented, “The doctor is in” may be a phrase of historical interest only.

Brian C. Joondeph is an ophthalmologist and can be reached on Twitter @retinaldoctor.

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  • Markus

    I have asked this before. Since ICD-10 is in use all over the world, what changes have doctors in Canada, Britain, Germany, etc noted? There must be some users out there.

    • LeoHolmMD

      Agree. Lets hear from someone who is using this and see what happened. I looked on YouTube a few times and could find no example of any physician actually demonstrating ICD10 use in practice.

      • https://twitter.com/retinaldoctor retinaldoctor

        Not in use in the US yet. Not possible to use it in the US. None of the insurance companies including Medicare/Medicaid are able to accept these codes in their computers so no point in any US physicians trying to use ICD-10 codes to bill. The test will be when it is implemented and obviously the US system is not ready to even test it, hence the delay.

      • Ava Marie Wensko George

        Probably because in America it would constitute a HIPAA violation….

    • NewMexicoRam

      My understanding is that in other countries, it is a clerk who defines the final ICD-10 code, not the doctor or provider. In the USA, the doctor has to certify the final code, then some other clerk gets to deny the code, and so on and so on.

      • https://twitter.com/retinaldoctor retinaldoctor

        Correct. I work in the public hospital system in New Zealand a few weeks per year. I don’t do any coding whatsoever. As it is a government run and paid for system, as it is in many countries, coding is for statistical purposes only, not for billing.

        • ninguem

          THANK YOU.

          I’ve been asking for some time, if real-live rank-and-file practicing physician physicians actually use ICD-10. Meaning, the physician has to pick the code, and is somehow penalized if that doctor uses the wrong code.

          Thanks for reporting from New Zealand.

          NewMexicoRam, I have cited a few articles in prior KevinMD threads on ICD-10.

          YES, they have been having trouble with ICD-10 elsewhere, YES, it is a hassle, but they’re accepting it overall.

          It DOES degrade practice efficiency, because of the time needed to use the cumbersome ICD-10 system, and it is important to realize that it is NOT turning out to be a learning curve. Meaning, efficiency is not returning as everyone gets used to the new system.

          In fact, patient care slows down, the back office work is that much less efficient. Fewer patients are seen per hour. Fewer charts are processed in the back offices. Healthcare becomes that much more expensive. They’re finding in other countries that it stays that way, the inefficiency is permanent, it does NOT eventually return to the status quo ante.

          Healthcare is now that much more expensive. Hope it’s worth it.

      • Ava Marie Wensko George

        It is not a clerk….It’s a professional coder. We also have professional coders in America in the hospital setting. Private physician practice offices have them as well. The impact of ICD-10 will be on those physicians who are required by hospitals to code, which I think takes them out of the practice of medicine and into the world of the professional coder – Which is not where they want to be.

        • NewMexicoRam

          OK.
          Now I see you used the term “physician” and not “provider.” I’ll try to remember your point.

          It still means I’m performing tasks at a level less than my training.

        • T H

          Not many private clinics can afford to pay a professional coder: most use a service of some sort.

          And in the US it will be primarily used to deny payment when the details of the code do not exactly match the details encoded in the ICD-10.

          As in, “I see here the code says it was while skiing. But your note says ‘snowboarding.’ Since this is an obvious attempt to defraud us we are denying payment and will be auditing your files going back 5 years.”

  • Patient Kit

    “When physicians pay more attention to their computer screen or tablet than to the patient, guess who suffers? This is the reason why texting and driving is illegal.”

    I’ve actually felt, at times, that the primary care resident at the hospital clinic was slightly annoyed and frustrated that I – the patient — was in the same exam room with him, distracting him while he struggled with the computer.

    By contrast, my attending GYN oncologist at the same hospital with the same computer system, has never once been on the computer while in the room with me. He makes eye contact when we are talking.

    The difference is like night and day. I trust my GYN ONC with my life but couldn’t care less whether I ever see the primary care doc again. I will do whatever possible when making insurance choices to be able to stay with my GYN ONC. I kept hoping the (not my) primary care resident would cycle out of a rotation and be gone the next time I needed to see a primary care doc. But he stayed in that clinic for a whole year now. If I’d known he was going to stick around this long, I might have requested a different resident. But I was reluctant to do that to a resident. He wasn’t that bad. I just
    don’t really like him or really trust him. He’s always super stressed out, spends most of his time struggling with the computer and he stresses me out. I go to primary care as infrequently as possible.

    How ironic is it that seeing a primary care doc is a stressful experience and seeing my GYN oncologist is a calming experience?

    • LeoHolmMD

      Is it possible your GynOnc has a scribe, or is not even required to use the EMR? Although Primary Care has been saddled with the majority of the burden of MU, PCMH, etc, they are rarely given the resources to contend with it. Hence your PCP is consumed with data entry instead of paying attention to you. (In addition to the usual adjustment period of residency).

      • Kristy Sokoloski

        My PCP sometimes uses a scribe (but not always), uses the EMR, and he still looks at me when we are dealing with a problem. My rheumatologist at first had a hard time with the EMR but now he’s gotten better at it and yes he still looks at me and does an actual exam.

      • Patient Kit

        Good question. I don’t know, but I don’t think so. I never heard of scribes until recently. Would I know if a scribe was in the room with us?

        He does frequently have a resident with him. And he has a female (nurse? MA? resident?) with us when doing a pelvic exam. Once, while in the exam room, I asked him about my specific CA125 #. He knew that it was good but sent a resident to go check my chart — on a computer outside the exam room — to get the exact # for me. And another time, he asked a resident to print out a copy of my pathology report for me.

        I’ve seem this doctor 5 or 6 times now, not counting the day of surgery or in my hospital room the day after surgery, and he has never been on the computer while talking to me. Once, midway between my 10-day and 3-month post-surgery visits, he spent 20 minutes talking to me on the phone. I bet he had my chart in front of him then. But never when we are face to face.

        Would different docs in the same hospital have different EMR requirements? I just assumed he had to be using the same EMR system as my primary care doc. My GYN ONC has been seeing me in the clinic because I am a Medicaid patient. But for my 10-day post surgery visit, I was seen in his private office in the hospital because he had a scheduling conflict that didn’t allow me to be seen in the clinic soon enough. He has a PA in his private hospital office working with him.

        To be clear, I am not anti-resident. I’ve gotten excellent specialist care in a NYC teaching hospital while on Medicaid. I know that residents are part of the deal at a teaching hospital. And I think my GYN ONC must be a great teacher for his residents, based on how he listens to me and answers my questions. Communication and compassion are definitely two of his strengths. Plus he’s a great surgeon.

        I just haven’t been as lucky in the primary care clinic.

        • guest

          I think what’s going on is that the attending doesn’t have to do anything with the computer because the resident who is with him is responsible for writing the notes when they see you together.

          It may also be a generational thing; I prefer to see the patient and write my note on the computer afterwards, Your GYN-Onc attending may be doing that, since he likely has the luxury, as I do, of having some free time at the end of the day to catch up on charting. I notice that the younger attendings and the residents are more likely to lug their laptop into the exam room and write their note while they see the patient.

          • Patient Kit

            The GYN resident doing the notes makes sense. I don’t think it’s a generational thing though. My GYN ONC attending is only about 40. I’ve never seen him on a computer in the exam room, but he’s certainly not tech resistant. He did my surgery robotically. Different thing, I know, but still. Maybe it’s just his style as an oncologist because he’s talking to his patients about cancer? However he does it, I assume his notes have to enter my EMR one way or the other.

      • https://twitter.com/retinaldoctor retinaldoctor

        Scribes make a huge difference, allowing physicians more time to interact with their patient, rather than with a computer or tablet.

        This is a good article from the WSJ from a few weeks ago on the subject of scribes.

        http://online.wsj.com/news/articles/SB10001424052702304418404579469371577995400

    • T H

      I am sure that your Gyn Onc’s schedule is much more lenient than the average doctor’s schedule… 1-2 patients/hour vs 4-6/hr. In addition, he probably dictates his notes which are then transcribed into the EHR by someone else.

      Why? Gyn Oncs bring in huge amounts of money: if they’re not evaluating people for surgery/chemo, performing surgery/prescribing chemo, or doing follow-ups for the same… then they’re not making the hospital money.

      I can point to my own little rural hospital: the Urologist does not use the EHR; neither do the Heme Onc, Vascular Surgeon, or Interventional Radiologist. They dictate into the paid-by-hospital-dictation-system and two hours later sign their transcriptionist generated notes when they appear in the EHR. It is a fine system and one that I, as an ED doc, wish I could access.

      • Patient Kit

        Thank you for the insight. I do not know the particulars about how my GYN ONC and primary care docs (in the same hospital) get their notes into the EMR system. The main point I wanted to make is that, from this patient’s POV, it makes a huge difference in my relationship with my doctors whether or not the computer is a barrier between us.

        Did all doctors used to routinely do the dictation/transcription thing with their notes? I know my two private practice orthopedic surgeons both dictated their notes. If it used to be routine but is not anymore, why did that change (regardless of whether the notes get transcribed into a paper or electronic chart)?

        • T H

          I wouldn’t say ‘routinely’ since transcriptionists can be expensive. Of course, now there is fairly good computer-aided transcription that can be extensively customized (also expensive).

          It is cheaper in the short run to have docs do their own typing. It is an open question at this point whether or not the long term costs outweigh the short term costs. Of course, since it is hard to get politicians and business people to even look at long term issues, it might be a moot point.

  • Kristy Sokoloski

    Didn’t doctors also have a lot of complaints when ICD-9 got implemented way back when? Including making the statement that some of the codes used to describe things like in the example you gave was silly? How would your example about the opera be coded by the ICD-9 standard if someone got seriously hurt at the opera?

  • http://www.idealmedicalcare.org PamelaWibleMD

    Isn’t it being delayed until October 2015?

    • https://twitter.com/retinaldoctor retinaldoctor

      Yes we are fortunate to have “eye codes” which have less onerous requirements compared to the E&M codes. I don’t know how long we will have them though. There is talk of getting rid of them. Not all insurances allow their use. Medicaid for example does not.

      I like your IDIOT example.

    • ninguem

      Pam are you in any insurances at all?

      Private insurance? Worker’s Comp? Tricare? Medicare? Oregon Health Plan or any mangled care Medicaid?

      It may well be that ICD does not apply to you, in any way.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Brian ~ How fortunate that you are limited to eye codes. Imagine how fun it will be for the average family doc. . . .

    It’s not ICD-10 – It’s ID-10-T (aka IDIOT).

  • Kristy Sokoloski

    I see where you are coming from, but I think that the reason that it is asked for about where they got hurt, or what they got hurt on (taking a fall from a bike riding through the park, this example I learned about through going to school for Medical Assistant) is in case more of an investigation in to the incident needs to be done by the State. The insurance companies are not the only ones that use this information. The same applies when epidemics happen in areas throughout a city or a State.

  • Patient Kit

    Thank you. I didn’t think of the residents taking on the scribe role. But that makes sense. I don’t remember the residents being on a computer in the exam room either though. Maybe they do it when they step out of the room. Or maybe the GYN residents are just better at using the computer more unobtrusively than the primary care resident.

    But, to be fair, I’m focused on the primary care resident since he’s the only one in the room with me. But I’m focused on my GYN ONC, not his residents, when they’re in the room with me. And the subject is my ovarian cancer, so I’m really focused on what he’s saying and how he’s saying it.. I have to be making eye contact with a doc when we’re talking about something that serious. So, maybe I just didn’t notice what those GYN residents are doing. Primary care resident is struggling big time with the EMR though. And it is a huge barrier between me and him.