Saving Patient Ryan (a true tale of modern health care)
Office manager: “Doctor, the insurance company has kicked out your claim for patient Ryan. They won’t accept your ICD-10* diagnosis code.”
Doctor Miller: “What? Why? I know I coded this correctly.”
Office manager: “They said it is not specific enough.”
Miller: “I used N63 (breast mass). Ryan has a mass in her breast that needs to be removed. It could be cancer but we won’t know until I remove it. What am I supposed to code?”
Officer manager: “I don’t know. What are your orders, doctor?”
Miller: “We have crossed some strange boundary here. The world has taken a turn for the surreal.”
Office manager: “I agree, but the question still stands.”
Miller: “Contact the insurance company’s clearing house for coding and ask them what they want from me.”
A little while later…………………….
Office manager: “Doctor Miller, I have your answer.”
Miller (sighing): “Well, what is it?”
Office manager: “They changed the codes. N63 has been expanded to 18 different codes and you have to use one of them. “
Miller (incredulously): “18! How do you get 18 codes out of “breast mass”?”
Office manager: “You have to specify the location of the mass- right, left, or unspecified quadrant of the breast; tail of the breast; sub-areolar, etc. They have 18 choices and you have to pick one.”
Miller: “How am I supposed to know this? My 2017 ICD-10 code book only has N63.”
Office manager: “It is in the 2018 book, which we haven’t received yet (it is, after all, only September of 2017). I have ordered the new 2018 books (at $100 apiece).
Miller walks away muttering to himself, an increasingly frequent activity. “What difference does this specificity make? It is a breast mass. Where it is in the breast does not change the level of the visit or the procedure being done. Who needs to know this? The patient doesn’t care. The insurance will pay the same for the treatment. It has no bearing on anything to do with the medical care I provide to patient Ryan.”
Miller (to himself): “Wait! By denying my claim, the insurance company can delay payment and hang on to its money longer, money that no doubt is earning interest for them as we speak. The more specific they make the diagnoses, the more likely they will be able to deny claims that do not meet their detailed specifications to the letter, or number. Some doctors will probably give up pursuing some claims because the hassle just isn’t worth it. This is a potential gold mine for insurers.” He goes on (admiringly). “It is brilliant. Under the guise of improving care they have made it both more difficult for doctors to file claims and easier for them to deny payment.” Miller brightens. “I’ll check with my financial advisor and see if I can afford to retire yet.” He pauses. “Then, again, maybe if I stay and just take the best care of patient Ryan that I can despite the coding Nazis out there, someday I can look back and say that saving patient Ryan was the best thing I could have done.”
Diagnosis coding for physicians has become data mining, pure and simple. There is no logic or rationale for increasing specificity of diagnosis codes to the point where we have gone from 13,000 diagnosis codes with ICD-9 to 68,000 with ICD-10, including codes for walking into a duck or cow, getting injuried from burning water skis, and relationship problems with in-laws (who doesn’t have that?). Most of the new codes do not alter what the physician bills the insurance company, either for the evaluation or the treatment of the condition.
I am no longer a doctor, health care provider, or even a vendor in the eyes of insurers and the government. I am now a data gatherer for them. If things sink much lower, we may have to re-classify medical schools as vocational technical schools. I can see it now: University of Miami Vo-Tech School of Medicine. It does have a certain ring to it.
*International Classification of Diseases, version 10