The effect of switching to ICD-10 coding structure

Issue: June 2012

ByWilliam T. Gerson, MD

William T. Gerson, MD
William T. Gerson

Bureaucracy is a giant mechanism operated by pygmies. — Honore de Balzac

The organizational culture of medicine used to be dominated by the ideals of professionalism and volunteerism, which softened the underlying acquisitive activity. The restraint exercised by these ideals now grows weaker, the ‘health center’ of one era is the ‘profit center’ of the next. — Paul Starr

We cannot individually, perhaps, build the future of medicine, but we can resist those changes that threaten the essence of our profession. Unless the 1-year delay proposed by the Department of Health and Human Services is accepted, as of October 2013 our practices will have to be compliant with the new ICD-10 coding structure. If you haven’t heard about the required transition, you soon will.

The latest revision to the ICD began in the 1990s. Despite recent delays in the implementation deadline, it is apparent we will be granted no more reprieves from this onerous and misguided bureaucratic folly. While the offspring of the noble statistical study of disease first begun in the 16th century, the current version as worshipped in the United States is phantasmagorical. With five times the number of codes as ICD-9, no consistent correlation with past codes, and such detail that the estimate of permanent increase in physician documentation time is 3% to 4% (for a total now to be 15% to 20% of our time), I’m sure you are as excited about this change as am I.

Effect on finances

That truth goes without mentioning the financial effect of implementation. In 2008, Nachimson Advisors, retained by a number of medical professional organizations (including the American Medical Association), estimated that the effect on total cost of the ICD-10 mandate for a typical small practice (three physicians and two administrative staff) would be $83,290. For a typical medium practice (10 physicians, one full-time coder and six administrative staff), the estimate is for $285,195.

For large practices — your referral hospital, perhaps — of 100 physicians and their staffs, the cost comes in slightly south of $3 million. But for this, you get to distinguish between shark and dolphin bites, and whether the trauma was to the right or the left leg. Good thing you recently invested in a new electronic health record and likely welcomed reimbursement limitations because you can now enjoy even tighter cash flow in your practice.

Of course, the bureaucratic hope is that your quality of care will increase proportionately with your angst. I think not. I was taught that documenting a patient’s story in the chart was the first step in understanding the patient, the reason they were there and the crucial threads that you would ultimately weave together in your mind (and later document in the chart) to uncover the underlying diagnosis. With yet another intrusion into our exam rooms, I believe we stand to lose the most powerful quality improvement project we possess — our minds.

Those of us of a certain generation will likely continue to see patients in the same manner we always have. We will just add the additional documentation time to the end of our office days, or more insidiously to our evening and weekend family time — organizationally efficient but not personally. We might be at home, but unavailable to family members as we complete our tasks on a laptop on the dining room table. Current trainees who have had protected time designed into their days will practice under a new paradigm with efficiency coming from less time spent with the patient, or more work being done by non-physicians. There is no other option if efficiency is our paramount goal.

Barry Schwartz, a psychologist at Swarthmore College, recently wrote in The New York Times of the danger of too much efficiency. His comments were directed at our economic institutions, including venture capitalism, but his message has import for the world of medicine. Increased efficiency is the only way for a nation’s standard of living to improve and one way for health care to become less expensive — but at what true cost?

Efficiency as an enemy

Schwartz said friction in all of its forms is the enemy of efficiency. Organizations, thus, attempt to decrease friction to increase efficiency. In medicine, we are subject to this same standard, increasingly so it seems, although we still largely manage to fail. Much of the failure is due to those physicians who relish friction or even advocate for more. I congratulate them.

A reference to Aristotle’s ethical doctrine of the mean is made by Schwartz as he attempts to explain the potential dark side of efficiency. To Aristotle, ethical virtues lie between extremes. Virtue is intermediate between states of excess or deficiency, and not as Plato believed a form of knowledge. Aristotelian ethics has relevance for physicians juggling the pressures of efficiency. If efficiency is a virtue, then it cannot be worshipped in excess. Trusting efficiency while discounting friction is a mistake. Our challenge is to find the mean. Efficiency is important, but let’s be honest about its implications — both to us and to our patients.

Equity and access in health care affect how resources will be used. Advocacy for just, efficient, effective and quality care in medicine is virtuous. Virtue as a physician, however, lies with our own autonomy. Maybe we can, and should, force a stop to ICD-10.

Reference:

Schwartz B. Economics made easy: Think friction. The New York Times. Feb. 19, 2012;Opinion section:SR5.

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William T. Gerson, MD, is a clinical professor of pediatrics at the University of Vermont College of Medicine.