Sunday, November 15, 2015
ICD-10: the Imminent Cause of Disaster (part one)
On October 1, 2015, the government of the USA mandated the use of the International Classification of Diseases version 10 (known as ICD-10) for all diagnostic coding.
A patient came to see me recently, after October first, having a soccer injury: he was cleated on his right great toe. Examination showed he had a minor, fracture of his right great toe and a painful subungual hematoma (blood under the nail). The coding starts out easy: W21.31XA: "struck by cleats, initial encounter". Then it proved more difficult: S92.424A: "Non-displaced fracture of right great toe, distal phalanx, initial encounter, closed". It was s much more difficult in that there are tens of thousands of fractures in the list. Sorting them is a Herculean task. The last code proved impossible. There is NO specific code for a subungual hematoma. None. Internet research showed that many toenail diagnoses are all listed under L60.8 - “Other nail disorders”:
Acquired nail displacement
Acquired nail discoloration
Congenital clubnail
Congenital koilonychia
Congenital malformation of nail
Hemorrhage of the nail (subungual) (HERE IT IS!)
Leukonychia (punctata)
Leukopathia unguium
Onychophosis
Onychoptosis (pitting)
Congenital flat nail - platonychia
Acquired remnant nail
Fngernail shedding
Spading nail
These diagnoses have no biological, pathological, diagnostic, therapeutic, or any factor in common, other than they have to do with "nail". No mention is made of right or left, finger or toe, number of digit, or anything else that clarifies to a level parallel to that provided for fractures. They are all classed under one code. It is unfathomable how this clumping of unrelated diagnoses could ever serve research, teaching, patient care, or standardization of the medical record.
And yet we are mandated to use this system. Billions of dollars have already been spent. A divide in data-continuity has occurred: all the data prior to 11/1/15 is obsolete and does not map into ICD-10. I may just set my water-skis on fire, jump off, and see what happens!
The promise is that the new codes, more than five fold longer than ICD-9, the prior version in use for over thirty years, will be more thorough and specific, allowing for greater “data-mining”, research, as well as improved patient care and outcomes.
The threat is that if physicians and medical institutions do not use the new codes, and use them correctly, there will be dire financial penalties.
I have been studying the old codes for over thirty years and the new codes for the past two years. I have been using the new codes for a month and a half. I can, without hesitation, state that ICD-9 was deeply flawed, but that ICD-10 has deeper and more abidingly dangerous flaws.
In a nutshell: ICD-10 is a failure of design. The diagnostic codes are capriciously variable in their inclusiveness and exclusivity, unpredictable in depth and breadth, and , at times, bizarre in the inventiveness.
Here are but a tiny sampling of the flaws and how they are just plain wrong:
Multiple sclerosis (MS), a common neurological illness, with protean manifestations, wide ranging severity, and multiple patterns of progression is all classified as G35. This is an uncorrected problem from ICD-9 which also had a solitary code for all of MS. Chronic stable, relapsing-remitting, and progressive MS are all G35. MS that causes a transient loss of vision and does not again manifest until there is a foot drop two years later is classified the same as MS that starts rapidly and marches relentlessly until the patient is paralyzed from head to toe are both G35.
A poor soul out water-skiing manages to, improbable as it seems, ignite the skis. He jumps from the burning water-skis, but tragically drowns. " Death by drowning and submersion due to falling or jumping from burning water-skis" has THREE codes: V90.27XA, V90.27XS, and V90.27XD. The first is for the initial visit (at which he is pronounced dead), the second is for the follow-up visits (at which he is still dead), and the third code is for visits to handle “late sequelae” of the initial visit (I assume that the patient is now dead and the late sequelae includes putrification). Really. And there are sets of three parallel codes for drowning after jumping or falling from all manner of water craft: commercial boats, passenger ships, canoes, inflatable craft, sailboats, etc. The “X” in the code is a “reserved digit” for “future additional specification". Perhaps it will be used for the color of the water-skis or craft. The lists, by the way, are repeated for crafts that overturn, crafts that sink, crushed crafts, and other accidents. There are over one hundred sixty codes in this section... with reserved digits for more.
A patient came to see me recently, after October first, having a soccer injury: he was cleated on his right great toe. Examination showed he had a minor, fracture of his right great toe and a painful subungual hematoma (blood under the nail). The coding starts out easy: W21.31XA: "struck by cleats, initial encounter". Then it proved more difficult: S92.424A: "Non-displaced fracture of right great toe, distal phalanx, initial encounter, closed". It was s much more difficult in that there are tens of thousands of fractures in the list. Sorting them is a Herculean task. The last code proved impossible. There is NO specific code for a subungual hematoma. None. Internet research showed that many toenail diagnoses are all listed under L60.8 - “Other nail disorders”:
Acquired nail displacement
Acquired nail discoloration
Congenital clubnail
Congenital koilonychia
Congenital malformation of nail
Hemorrhage of the nail (subungual) (HERE IT IS!)
Leukonychia (punctata)
Leukopathia unguium
Onychophosis
Onychoptosis (pitting)
Congenital flat nail - platonychia
Acquired remnant nail
Fngernail shedding
Spading nail
These diagnoses have no biological, pathological, diagnostic, therapeutic, or any factor in common, other than they have to do with "nail". No mention is made of right or left, finger or toe, number of digit, or anything else that clarifies to a level parallel to that provided for fractures. They are all classed under one code. It is unfathomable how this clumping of unrelated diagnoses could ever serve research, teaching, patient care, or standardization of the medical record.
And yet we are mandated to use this system. Billions of dollars have already been spent. A divide in data-continuity has occurred: all the data prior to 11/1/15 is obsolete and does not map into ICD-10. I may just set my water-skis on fire, jump off, and see what happens!
