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.

Fiscal fallacies

We're shopping for a new dentist, and the reasons illustrate one of the cherished fallacies driving opponents of healthcare reform. This fallacy is that if providers don't have third-party payers to pick up the tab, then they will lower prices to the level their patients can afford (like two chickens or a couple of dozen eggs?).

That Hippocratic horse left the barn a long time ago.

Our particular tale begins with my wife's last semi-annual prophylactic visit a few months back. The hygienist thought she detected decay under one of my spouse's old fillings. Hold that thought while we move on to my semi-annual visit this summer. I told the hygienist that I was feeling a little sensitivity in the vicinity of my bridge.

See if you can detect the similarities in the next steps. In my wife's case, the dentist recommended a full porcelain crown, not a new filling, a cost difference of about $2000. In mine, although I got prescription toothpaste for sensitive teeth (which has worked, BTW), I got a recommendation to remove my nine-year-old bridge (which means breaking it, according to this dentist) and replace it with two crowns, an implant, for about $6000 more than the average cost of a permanent bridge.

"Of course," he said, even though we don't have dental insurance, my wife's flexible spending account (FSA) would cover the costs.

Oh no it won't. Even though FSAs are supposed to be usable at the discretion of the person who owns the account, her account informed my wife that they won't cover either crowns or implants, which they consider cosmetic. Even if they would cover these procedures, the total tab would still be many thousands more that the account would cover.

Two weeks ago, I told the dentist there was no way in hell I could afford such costly treatment. Now according to the Republican rubric, that should prompt a counter-offer from the provider. There has been silence, no more than I expected. We're both looking for second opinions, and also for treatment that we can afford: our budget isn't much over the two chickens level.

When we started with this dentist, I had a fair income and a good dental plan. Now we have neither. This dentist's treatment programmes and pricing models are indeed based on what the third party will pay. But when he deals with a third-party payer, he is obliged to justify his treatment. This is known in the business as proving medical necessity. He proposes A. The payer says, "if you can't prove the necessity we'll only cover B." Provider, patient and payer end up somewhere in the middle.

With a self-pay patient, providers have no incentive at all to hold down their costs. The can trade on the innocence of their patients to bill them for as much as they can. They know that once they present the bill, the law will be on their side when it comes to collection from a self-pay patient. That's why you can kiss that two-chickens payment model goodbye. As patients, our only choice is to say no to this dentists, and hope we can find treatment we can afford. If we can't, we'll go without.

Not even the Affordable Care Act helps much. Although good dental hygiene is now proven to be the first line of defence against many internal diseases, it remains glaringly absent from most discussions of healthcare. It's a frill, an extra. Most dental treatment can be shuffled off as cosmetic by payers, even those who sell dental insurance.

Opposition to real affordable care in this country is driven by equal doses of delusion and greed. Nothing about that will change until the bodies start piling up in the streets and frightening the horses.