It was only about 10 minutes into the game when I fell on the soccer pitch this summer and tore a ligament in my knee. My subsequent trip to the hospital garnered me a specific diagnostic code that went to my insurance company. My insurer was then able to see why I sought care and billed accordingly. Despite significant upgrades in medical knowledge and care, the same thing would have happened a decade ago. Those codes have remained largely unchanged for more than 30 years. But soon a big change to that collection of numbers and letters may be making a splash—and should bode well for consumers.
Come October 1 a code update will go into effect that will take the current 19,000 diagnostic and procedure codes and catapult that number to 142,000. The transition promises to offer greater granularity to why we seek care. It gets wonky, but with the change researchers that deal in health data might gain more insight into what types of care get good results. That know-how could then trickle down into better care for you. Soon, instead of a code that simply indicates “torn anterior cruciate ligament” there will be separate codes that directly correspond to whether I tore the ACL in my right knee versus my left. Was it my first visit for care for this injury? The new coding system will cover that, too. Under the new system one code will indicate I tore my left ACL and this was my first visit for care. That larger compendium of choices will provide greater specificity for my doctor’s future reference and also for insurers trying to suss out whether my care was necessary. Yet one of the most significant aspects of this change continues to go largely ignored by medical workers bracing for rejected insurance claims and frustrations next month: More detailed medical billing codes could eventually improve your health care. Those new codes could provide a clearer picture of why individuals seek care and which health problems are growing or contracting in communities —helping inform what health issues should be researched and improved. At least, that’s the hope.
At the same time, some clinicians anticipate serious headaches as insurance companies and medical providers adjust to the new system—called the International Classification of Diseases (ICD-10). It is dizzyingly complex. Compared with the 15,000 diagnostic codes in the current system there will now be 70,000. The number of codes for inpatient hospital procedures—now totaling in at 4,000—will spike to 72,000. Many of the codes will not be needed on a regular basis (like V97.33CD, which indicates you were sucked into a jet engine, and this is your subsequent visit to a doctor). “The average internist probably won’t need more than 40 to 50 ICD codes for diagnosis,” says William Rogers, the ICD-10 Ombudsman for the Centers for Medicare & Medicaid Services (CMS) and a practicing emergency physician at Georgetown University Hospital. But officials overseeing the transition at hospitals and the doctor’s office are expecting a significant learning curve. “Other countries have said coders have become very confident in their coding probably within six weeks to six months,” says Lynne Thomas Gordon, CEO of the American Health Information Management Association.
In anticipation of these difficulties, CMS announced that during the first year of this new policy they will not reject valid insurance claims as long as health claims were in the right ballpark. That means if you coded for heart failure but did not click the most specific code for “heart failure” the physician will still get paid (or the insured patient will still be reimbursed). “The policy says you didn’t get the exact right one, but you got the right category,” says Pat Brooks, a senior technical advisor for CMS.