Q&A: Why the U.S. actually needs those crazy ICD-10 codes

By Tom Sullivan
08:22 AM
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For a bit of perspective on medical coding: ICD-9 was developed in the 1970’s — in the 70’s people could smoke in the hospital.

Fast forward to 2012 and the raft of ICD-10 jokes began, hitting the big time when the Wall Street Journal called out some of the ostensibly zany codes, like injuries caused by macaws, and countless other publications followed suit with jabs about second encounters with lampposts, flaming waterskis, and more. Adding to the fun, certain Congressmen cracked jokes of their own.

But lost amid the comedy, particularly on the national level, has been anyone publicly challenging those punchlines and explaining exactly why the U.S. as a nation really needs the new code sets.

Government Health IT Editor Tom Sullivan spoke with Richard Averill, senior vice president of clinical and economic research at 3M Health Information Systems about the reason for macaw-related codes, population health implications of more specific diagnostic and procedural data that have the potential to create actionable information for things like sports related injuries — and why ICD-10 is just like any other dictionary.

Q: Among the jokes about ICD-10, the one that raised my eyebrow was the injuries related to macaws, particularly since the various species of macaws are almost entirely native to South America. But why does the U.S. need a code for macaw injuries?
You’ve got to remember that the avian flu was originally transmitted by a bird. If there was an outbreak of something in the U.S. suspected to be carried by a bird, we’d have the code and the CDC could require that it be reported. 

On those codes, there is no obligation for anybody to report them, except in very special circumstances. There’s a small section of that segment of the codes in ICD-10 that deal with injuries due to intervention of the medical system. So there’s a code for when you’ve operated on the wrong limb. CMS will require that tiny handful of codes in this particular section to be reported. Other than that, CMS does not require the reporting of codes in that general section that everyone continues to use as examples.

[Visit our new eSupplement ICD-10: Compliance & Beyond.]

There have always been these codes in I-9. Another example is a code for someone on a bicycle getting hit by a railroad car. These codes have always been there, there’s never been a problem because people aren’t required to report them, there are just more of them in I-10. 

Q: The fact that there are more of them definitely concerns a lot of people and then there’s the argument that particularly for specialists, most physicians and coders will only use a small subset of the new codes anyway.
In a lot of ways you have to think about the coding system like a dictionary. There are 470,000 words in the unabridged dictionary. Well, we’ll use 1-1000th of 1 percent of that number in this conversation. But the fact that there are 470,000 words in the dictionary doesn’t make it any more difficult to have this conversation. Indeed, in my lifetime I will only use a tiny fraction of the words in the dictionary. Same goes for the coding system. Under certain circumstances, one may want to use a particular code to describe something unusual, but the vast majority of situations won't call for that. No one will ever have to use a large subset of the codes in I-10. If you’re an ophthalmologist, you’re pretty much going to use the eye codes; that’s what you're limited to in terms of describing what you do. Everyone who makes fun of these codes forgets the fact that no one has to report them except in very isolated circumstances.

John Hopkins Bloomberg School of Public Health noted that to further research in the area of non-fatal injuries we must be able to more accurately describe the nature of the injury sustained and correlate the nature of the injury with the mechanism of the treatment and outcome. So they’re arguing that we need the detail to really understand outputs. If one goes back and looks at the eight or so years in which the National Center for Health Statistics was soliciting input, it wasn’t bureaucrats making this stuff up, it was suggestions from the industry that we needed and wanted this level of detail for unusual circumstances and unless those occur no one ever has to worry about that code being there — just like there are lots of words in the English dictionary that are there but I’ll never have to worry about because I never have any need to use them.

Q: One of the points that emerged while reporting on the eSupplement ICD-10 Compliance & Beyond is that there’s an incredible amount of data we don’t have under ICD-9, actionable information that could tell, say, whether your child is more likely to get a concussion playing football than soccer…
Certainly, payers have the option of requiring providers to report those injuries and if they do then in all likelihood you’d be able to look at the circumstances of the injury, whether it was football, soccer, or whatever. So if we as a country required those sports related injury codes to be reported then we’d have national data to follow those things, trend those injuries. The exact chapter that everyone complains about, the external cause of injuries, is the chapter that if it was required to report those codes, we could actually track them. To me it would be perfectly reasonable to ask pediatricians to indicate when someone comes in with a sports related injury what sport caused that. We haven't made that a requirement yet.

Q: Now, if that data were required, it would be a relatively simple query to run, to figure out which sport results in more concussions…
Right. If it was required, that would be a trivial thing to do, to look at all concussions, to look at the circumstances which led to it and identify sports injuries that are trending, concussions increasing — is that related to certain circumstances? With that kind of longitudinal data we can begin asking questions like 'are patients who had these injuries having some kind of learning difficulties?’ or ‘are they having seizures later in life?’ All that would be readily do-able from the data. From a public health and an epidemiological perspective those would be very important questions to at a minimum research and understand if these kinds of things are in fact occurring.

Q: Everybody’s favorite example of how the more granular ICD-10 codes can be put to use for improving population health management is type 2 diabetes. But what are some of the not-so-well-known examples?
Take pregnant women, for example. In I-9 we don’t know the trimester. That’s a very helpful piece of information. If patients are getting preeclampsia or other complications, you have to know the trimester. In rheumatoid arthritis we don’t even know what joint is involved. And so if we’re really trying to understand care and a patient has rheumatoid arthritis in the knees, hips, and so on, your ability to recover from, say, a stroke may be significantly impaired, especially compared to having rheumatoid arthritis only in your little finger. There’s lots of information in I-10 that will be useful, it isn’t just a couple examples.

Q: Even the most recent reports from AHIMA and WEDI paint a bleak picture of industry readiness but, then again, Kaveh Safavi, Accenture’s head of healthcare for North America, told me that at least among his clients “the ICD-10 ship has already sailed.” What sense do you have as to where 3M customers are in terms of implementation? And what about the States, Medicaid, et. al.?
We promise to have all our I-10 software ready at a minimum a year in advance, so there’s tremendous pressure on us to make sure that we achieve that objective and indeed for much of our software it was two years in advance. And from the perspective of the pressure that we get to integrate our I-10 software into partners I-10 software, I’m perceiving our clients to be very far along, sort of what you said, the ship has kind of set sail. As software makers look out at building major new functionality for the 2014 timeframe, many are developing that in I-10 because they have to assume I-9 is not going to be there. So a lot of the development we’re doing, we’ve sort of switched to I-10 because we’re presuming it will be an I-10 world and I think that’s true of a lot of the vendors. The switch has already been made, it’s an I-10 world already. If you want a new product in 2015 you’re updating that now and have to do so in I-10.

Related Q&A: Part 2 with 3M's Richard Averill on the politics of ICD-10 timing

Macaw photo from Shutterstock.com.