Orca injury? There’s a medical billing code for that

Know someone who drowned from jumping off burning water skis? Well, there’s a new medical billing code for that.

Been injured in a spacecraft? There’s a new code for that, too.

Roughed up by an Orca whale? It’s on the list.

Next fall, a transformation is coming to the arcane world of medical billing. Overnight, virtually the entire health care system — Medicare, Medicaid, private insurers, hospitals, doctors and various middlemen — will switch to a new set of computerized codes used for determining what ailments patients have and how much they and their insurers should pay for a specific treatment.

The changes are unrelated to the Obama administration’s new health care law. But given the lurching start of the federal health insurance website, HealthCare.gov, some doctors and health care information technology specialists fear major disruptions to health care delivery if the new coding system — also heavily computer-reliant — is not put in place properly.

They are pushing for a delay of the scheduled start date of Oct. 1 — or at least more testing beforehand.

“If you don’t code properly, you don’t get paid,” said Dr. W. Jeff Terry, a urologist in Mobile, Ala., who is one of those who thinks staffs and computer systems, particularly in small medical practices, will not be ready in time. “It’s going to put a lot of doctors out of business.”

The new set of codes, known as ICD-10, allows for much greater detail than the existing set, ICD-9, in describing illnesses, injuries and treatment procedures. That could allow for improved tracking of public health threats and trends, and better analysis of the effectiveness of various treatments.

Officials at the Centers for Medicare and Medicaid Services declined to be interviewed about the new codes. But a spokeswoman said that the agency was “committed to implementing ICD-10 on Oct. 1, 2014, and that will not change.”

In a letter in November, Kathleen Sebelius, the secretary of health and human services, told Sen. Jeff Sessions, R-Ala., that the Medicare and Medicaid officials were working diligently to help doctors get ready. “ICD-10 is foundational for building a modernized health care system that will facilitate broader access to high quality care,” she wrote.

Still, the troubles with HealthCare.gov have given new ammunition to those urging a go-slow approach on ICD-10 and have made it harder for the government to stand behind assurances that the transition will go smoothly.

“Failure to appropriately test ICD-10 could result in operational problems similar to what the Department experienced with the rollout of HealthCare.gov,” the Medical Group Management Association, which represents the business managers of medical practices, said in a letter this month to Sebelius.

More time, more tests

The Medicare and Medicaid office now appears to be open to greater testing of the system. Also this month, the Obama administration relaxed some deadlines for parts of the health care law, and some deadlines under a separate law for enacting electronic medical records.

“I think that people at CMS understand the stakes with respect to ICD-10 in a heightened way as a result of HealthCare.gov,” said Linda Fishman, senior vice president for policy at the American Hospital Association.

Dr. John Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, said the need to prepare for ICD-10 and the Affordable Care Act and to achieve so-called “meaningful use” of electronic health records all at once could overwhelm computer staffs throughout the health care industry.

“It’s just this collective sum of activities that exceeds the capacity of the system to absorb it simultaneously,” he said.

He said his hospital was spending $5 million this year on ICD-10, $7 million for the Affordable Care Act, $2 million on meaningful use, plus $3 million to comply with a federal health care privacy law.

“Basically, I’m not doing anything but federal regulatory mandates,” he said.

ICD-10 has already been postponed by a year. It was originally scheduled to go into effect this past Oct. 1, which would have coincided with the rollout of the insurance website.

Some health care executives say predictions of a fiasco next Oct. 1 will prove as erroneous as those that said civilization would collapse on Jan. 1, 2000, because computers could not handle years beginning with a 2 instead of a 1 — the so-called Y2K issue.

“It’s not going to be a shock to the industry to confront this,” said Christopher Chute, professor of biomedical informatics at the Mayo Clinic. “We’ve literally had seven or eight years to anticipate it.”

A survey by the American Hospital Association in May found that about 94 percent of hospitals were moderately to very confident about being ready on time. Both the hospital association and America’s Health Insurance Plans, which represents insurers, said that their members had spent a lot of time and money getting ready for ICD-10 and that the changeover should not be postponed again.

Why codes?

ICD-10 is the 10th revision of the International Classification of Diseases, which is issued by the World Health Organization, though countries can modify it.

Having a common global code allows for easier collection, comparison and analysis of the causes of death and illness. Most other countries have already adopted ICD-10, at least for record keeping and in some cases for reimbursement.

The classification was first issued in the 1800s. An early one listed “visitation of God” as one cause of death.

But as medical knowledge and technology have improved, more codes are needed. ICD-9, which allows codes of up to five characters, has about 14,000 codes to specify diagnoses and 3,000 to specify inpatient procedures. The code, which has been used in the United States for medical statistics since 1979 and for billing since 2002, has run out of room to incorporate new knowledge and technology.

ICD-10, with codes containing up to seven digits or letters, will have about 68,000 for diagnoses and 87,000 for procedures.

While ICD-9 had a single code for certain repairs to blood vessels in the head and neck, ICD-10 allows specification of the particular vein or artery and the particular procedure used. Extra codes allow recording of whether a patient was visiting the doctor for the first time or a subsequent time for a particular problem, and whether broken arms and some other injuries occur on the left or right side of the body.

There are dozens of codes dealing just with the big toe — contusion of the right great toe, contusion of the left great toe, with damage to the nail or without, initial encounter or subsequent encounter, blisters, abrasions, venomous insect bites, nonvenomous insect bites, lacerations, fractures, dislocations, sprains, and amputation, not to mention the vague “acquired absence of unspecified great toe.”

From siblings to opera houses

ICD-10 has been the subject of jokes, however, for its catalog of possible injury causes, like those burning water skis. There are codes for injuries incurred in opera houses and while knitting, and one for sibling rivalry.

When it first proposed moving to ICD-10, the Medicare and Medicaid Services office estimated it would cost the government and industry $1.64 billion across 15 years on training, software changes and lost productivity. But it also said the system would bring $4 billion in benefits during that time, from more accurate claims and improved health care.

Lee Browder, national director of the Professional Association of Healthcare Coding Specialists, said the transition should not be too hard for coders. He compared it to the introduction of the extra four digits on ZIP codes — there were many more codes, but the concept was the same as before.

The transition could be tougher for doctors, because they will have to be more specific in describing a patient’s condition.

The government has said Medicare contractors will have a week of testing in early March during which doctors and hospitals can practice submitting claims. But the Medical Group Management Association and the American Hospital Association, among others, are pushing for more testing.

Rhonda Buckholtz, vice president for ICD-10 education and training at the American Academy of Professional Coders, said postponing the deadline would just push the problem down the road.

“It doesn’t matter what deadline we get,” she said. “We’ll find a way to not meet it.”