And now, back to a recurring topic

Whilst I'm taking deep, cleansing breaths on the TN front, I'm returning to an old favourite: ICD-10. I  recently discovered The Misadventures of Ada, in which we discover humour in the medical coding/documentation. The last time I went down this road, I was treated to an imbecilic rant by a troll who seemed to know nothing about the subject, save what he/she had picked up on the Interwebz (so it must be true, right?).

So fundamentals first. I didn't get my ICD-10 knowledge from Google. I've been a certified professional coder for eight years,  worked in health care documentation for three years, and took a certificate in coding before that. So it's just possible I know more than Google about this.

The funny, no, hilarious sections of ICD-10 have little or nothing to do with diagnosis. They come from Sections V through Y, which address external causes of accident and disease, or location of accident or disease. Their purpose is statistical, and they aren't there by chance. Everything you see in these sections has happened at one time or another, and every location is there because it's figured in some accident or disease in the past. These sections have been in all previous editions of the International Classification of Diseases (ICD) from the start. At one time the statistical purpose of ICD was its main function. The enumeration of diagnoses and procedures became the main purpose as its usefulness became apparent.

Why did so many people get their knickers in a twist about this? Because ICD-10 had opponents, chiefly among organisations with special interests, like promoting their own system. Those organisations knew how to manipulate public and legislative opinion. They knew that no layperson  would know that the external causes sections had always been there, and had always had codes that looked silly taken out of context. Thus they flogged that horse, instead of dwelling on, say, the greater precision ICD-10 offers when describing coronary artery disease. That's not funny at all.

Today, these sections are as funny to most coders as they are to the public. First, because many of us can go through our entire career without needing to use them. Second, because the real hilarity shows up when someone miscodes a cause. W56.02, struck by dolphin,  would be far funnier paired with, say, V05.02, "pedestrian on skateboard injured in collision with railway train."

One of my colleagues asked me if I could find external cause codes that accurately described her son's recent injury during a LARP event at a summer camp. It turns out I could. This stuff is obviously of more interest to insurance companies than to clinicians or anyone else, but it does have a purpose.

So browse The Misadventures of Ada. Then, if you want to use Google constructively, chase down the code in question using something like "ICD-10 code W56.02" and see what you find.

F 60.9*

Let me offer a notice to trolls, or even mere jerks, who wander in. I”ll be showing you the door quickly, very quickly if it appears you are particularly stupid. I avoid pissing contests with skunks.

Let's take the example of a genius who wandered in here last June and started ranting about my comments in support of ICD-10. Only trouble was, this fool couldn't read a calendar. I had posted those remarks 14 months earlier. I didn't expect to be blogging again and I didn't keep track of my last posts. So I replied, none too nicely, asking WTF had set this jerk off and pointing out the 14 month lapse.

ICD-10 was introduced on October 1 last, with about the same amount of sturm und drang which accompanied Y2K (remember that manufactured hysteria?) It's now a very done deal, so let's recap who was agin it and why.

1. First, people in the health professions who had fears, legitimate and otherwise, about the effect of introducing a new diagnostic coding system. Some were older coders who didn't want to face learning something new. Most of them were gradually won over by discovering that it's not that much different to what they were already doing. Others were physicians who were afraid implementation would cost too much. Well, it hasn't: chiefly because coders and other health information specialists had planned for a process of holding physicians' hands during the transition.
   
   
2. One special interest group in particular opposed it. ICD-10 CM (the diagnostic system) is just one part of the coding toolbox, as was ICD-9. There is also an ICD coding system for inpatient procedures, and Current Procedural Terminology (CPT), a procedural coding system for physician practices and outpatient services. Whilst ICD is an international standard, CPT is a proprietary system owned by...wait for it...the American Medical Association (AMA). Guess which organisation has been at the forefront of opposition to ICD-10? And why? Chiefly because of persistent rumours and fears that a version of the ICD-10 procedural system could supplant CPT, at great financial loss to the AMA. In the post my anonymous ranter hated so much, I posed the question cui bono? Who benefits from the opposition to ICD-10? Well, there, now I've named the favourite heavy of most ICD-10 proponents.
   
3. Journalists of the snarky and simple-minded variety didn't exactly oppose it, but mocked it, and my troll had clearly got hold of the mockery, As a proudly recovering reporter, I don't mind saying that most journalists today are both snarky and simple-minded, and show a consistent failure to get the whole story. It's true that of itself, the introduction of ICD-10 is a non-story, less interesting than the introduction of a new brand of men's underwear. But add a clever story line that makes it look like a bureaucratic boondoggle, and it has legs.
   
   The legs are supplied by a chapter of ICD (9 and 10) called External Causes of Morbidity. In ICD-10, this is just one of 21 chapters, and the only one that doesn't deal directly with clinical diagnosis. It exists chiefly for compilation of statistical data on morbidity. Because of that, this chapter, as in ICD-9, tries to anticipate all possible external causes of morbidity, based on previous evidence. In other words, the people who put those wacky things into code did so not because they guessed that some strange thing or other might happen, but because it had happened somewhere. We work from evidence, and we don't guess. To take two examples that cause great hilarity, patients in the third world can acquire a deadly fever from being pecked or bitten by a parrot. If an one airport worker has been sucked into a jet engine, it is an indictment of that airport's safety record. The funny or supposedly useless things in this chapter are neither, although we in the business laugh too. The media neglect to mention that ICD-9 contains equally incomprehensible codes in its External Causes chapter, for that would spoil the story.
   
4. Then we have trolls like mine (let's call him Mr. Dunning-Kruger) who only know what Google tells them, and then regurgitate it like a bird or animal vomiting food for its young. Neither reporters nor the Dunning-Krugers grasp that medicine is vastly more complicated than it was in ICD-9's heyday, 30 years ago. Some people who do grasp it are offended by the increase in complexity. I think it's fucking fine that we need a diagnostic system that matches the granularity necessary in the clinic today: one that vastly increases the possible descriptions of cardiovascular disease, for example, and also simplifies the list of diagnoses for hypertension. That's what's going on in the other 20 chapters of ICD-10, and it's not foolish at all.

I'm not going to make the same mistake the troll made, and post a rant six months old. These things have a shelf life. In this case, the successful adoption of a coding system whose purpose is beyond a troll's comprehension makes his rant especially rancid.

*The title is an ICD-10 code I chose in honour of Mr. Dunning-Kruger. He threw at me the classic troll line of “Do your research,” completely overlooking the context: that I've done done my research on this topic for six years: real research, not half an hour on Google, and sat an examination on the subject. Although (disclaimer) I do not diagnose or treat disease, the code in the title seems to fit the average troll admirably. Do your research, pilgrims, and see what you think.

Mad as hell

Congress and the POTUS, in their wisdom, have once again "delayed" implementation of the new diagnostic and inpatient procedure coding system, ICD-10, by a full year. The coming deadline, October 1, 2014, was sworn by CMS to be what is called in IT a "drop-dead" deadline.

The entire idea of modernising the system is anathema to certain well-funded interests in the medical industry. Evidently those interests have more clout than the interests who think it would make a great deal of sense to have the same system as the rest of the world, because they did more than kill the deadline. They turned this reform into a political bargaining chip, and made it obvious that implementation can--and probably will--be delayed indefinitely.

The other day, whilst having a beverage with friends not in health care, I alluded to the subject. This led one of them to indulge in mockery he had picked up somewhere. He had heard that the new system was full of ridiculous codes, far more than necessary.

Let us back up. This system, called the International Classification of Diseases, began as a method of keeping track of medical statistics, and broadened into one system for identifying diagnoses and another (used in the US for inpatient settings) for procedures. The details of the system vary from country to country, but the codes are much the same. When an American tells you that ICD-10 is absurdly detailed, it's a bit of American arrogance at work. To use my friend's example, why is it necessary to have a code for parrot bites? If he lived in a country with wild parrots, he might not ask. Those charged with tracking disease need to keep track of such things as psittacosis and avian influenza. The 35-year-old system America clings to only allows us to code "open wound." If the patient later presents with either of those diseases, it can be a mystery where it came from. Likewise, if you're Australian, codes that specifically identify a crocodile bite experienced whilst surfing is very important, as encounters between surfers and sea-going crocodiles appear to be on the increase in that country. Such things involve the integration of the actual diagnosis code with an entirely separate class of codes specifying where and why an injury happened or a disease was contracted. This is not new. It's been a feature of ICD coding for 50-plus years. My friend is keenly interested in statistics involving accidents between cars and bicycles. Given that cops (around here at least) are notoriously slack about reporting the details of such accidents, where does one think those statistics come from? They come from the coding of the circumstances of an accident. ICD-10 introduces a greater degree of granularity that is more and more needed in a complex world.

Since it appears the forces of reaction have won this one, let us think about why they are opposed.
First, it's one more change being presented to people unable to handle change. Second, it costs actual money up front, whereas the deficiencies of the present system cost theoretical money later--as in a malpractice suit that may or may not involve deficient diagnostic records. Third, physicians and surgeons have always had a problem understanding coding. This change places much higher demands upon clinicians to put detailed description in their notes. I find it hilarious that American doctors, who are seldom deficient in ego, are tacitly admitting that they can't learn a system that millions of secondary school graduates have learnt and are using around the world. So much for their conceit.

Since the next system, ICD-11, is already in beta in other countries, and since ICD-10 is already 10 years old, there are those who ask why the US shouldn't just skip to ICD-11. Short answer is learning curve. The principles and underlying technology of ICD-10 and 11 are much the same,  although 11 takes them several steps further. Both are very different from ICD-9. Going from ICD-9 to ICD-11 is like changing, in a few weeks, from Ancient Minoan to any modern language. The present transition isn't nearly as daunting (unless you're a doctor). Keep in mind that those who oppose this change, and have now smelled blood in the water, will continue to oppose any transition.

So when you read snarky remarks about ICD-10, and are asked to pass them on, remember to ask cui bono? And don't be made a tool of reactionaries. The current decision is, as 3M Corporation says in its press release, a vote for the past.