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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