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Federally-Mandated Medical Coding Gums Up IT Ops
Lucas123 writes "The change over from a medical coding system in use since the 1970s to an updated version that adds more than 50,000 new 7-character codes is being compared to Y2K as an IT project that is nearly impossible to complete on time. ICD-10, which replaces ICD-9, adds far more granularity to medical diagnosis and treatment. For example, ICD-9 has one code for a finger amputation. In contrast, ICD-10 has a code for every finger and every section of every finger. An 'unfunded mandate,' the change over to ICD-10 codes is a multi-year project for hospitals, state Medicaid organizations, and insurance providers. The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records."
While this is definitely a huge pain, I have little sympathy for those complaining about the timing of this when the standard was finalized in 1992.
The misattribution of the reason for rising costs in health care is unfortunate. The fact that government as a payor is in this system is one of the main reasons costs rise as such a rate.
I work on the revenue side at a fairly large health system, and due to our population we have approximately 50% of our patients privately insured, and close to 50% are government insured. (There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe). The privately insured generally repay approximately what's billed, but for the government paid accounts, we would do well to recover 50%, 40% is a better guess. This is because the government solves its own budgetary problems by withholding increases to its medical payouts. In this area, we're still being paid at 2002 rates in 2011. We never withhold a needed service, so we just eat the cost.
But we have to make the books balance somehow. We're non-profit, but we still have to keep the lights on. Charge rates have to go up across the board, and the money lost on literally every government paid patient who walks in the door is then made up by the privately insured. You hear about $8 tylenol being billed, well, tylenol has to cost $8 because you're actually buying a whole bottle and sharing it with everyone else.
I think we're going to continue to have a huge gap of misunderstanding while people continue to emote over "big business" and "fat cats" and "obscene profits" without understanding what the real financial issues are on the ground.
Posted as AC due to PHB concerns.
They're versions, not digits. ICD-9 diagnosis codes (for some reason the International Classification of Diseases also has a set of procedure codes) use up to 5 digits in the form [0-9VE]##.##. ICD-10 is of the form X##.###X, except for some codes that have a "placeholder" to pad the middle of the code out to seven digits.
The real problem here is that insurance claim submission is real design-by-committee bullshit of the highest degree. It's an ANSI standard, a submember of ASC X12 so half the shit in there is unused crap needed for the other things X12 is used for, like wholesalers restocking their shelves or boats reporting their cargo, because apparently code reuse is so damn important to these people that the claim form has a section (completely unused for claims) for reporting credit card details. Of course, the insurance companies all took this design under advice and did their own shit with it. There's a code that identifies whether the insurance company is blue cross, medicare, medicaid and so on (that you have to put on the claim just in case blue cross forgot, and they apparently forget a lot, since if the clinic forgets to set this code properly, the insurance company uses every excuse possible to refuse to pay). Simple enough, right? Well when I started, we had an insurance company that used blue cross's servers for processing claims, so even though they weren't blue cross, this code had to be blue cross or BC's servers would shit themselves. Setting that aside, there's a completely separate code for what kind of provider ID you're sending (blue cross, medicare, medicaid and so on) because of course people are going to bill blue cross using medicaid IDs. Fortunately, the NPI did away with that bullshit (for the most part... medicaid here still demands provider IDs for checkups because they refuse to give up any hoops for doctors to jump through, and one of those was that the doctor had to use a different provider ID for checkups versus treating someone sick. Their computer system apparently cannot sort these claims out themselves... and yet if you bill a checkup on the wrong provider ID, the computer system can easily reject it. Hmmm...)
Ahem.... Anyways, instead of just adding a code to identify whether the diagnosis in question is using ICD-9 or ICD-10 (in the box the committee already created for the purpose of identifying the code being used), the committee got together and pretty much rewrote the whole damn thing. This is where IT got gummed up (it's getting better now). And believe me, you can talk about "legacy equipment" and other stuff til you're blue in the face, but claim submission is how doctors and hospitals get paid, that's where IT has been spending all of its time freaking out.