One of the great nuisances in medicine is diagnosis coding. According to Medicare and insurance companies across the US, each andevery disease must have a unique number. Everything must be quantified and recorded. Why? To facilitate analysis, number-crunching, regulations,reimbursements and, of course, we sometimes joke, to perpetuate the jobs of the coders themselves. They usually know the nuances better than the doctors do.

Sounds ridiculous? Is it truly possible to describe Mrs. Jones’ frequently upset stomach as a letter and number combination? But alas we must be accountable for what we do. Value and quality are the buzz words these days.

The Electronic Health Records (EHR) are supposed to help us do this, but they really don’t. So here’s a quick tour borrowing from the PowerPoint that family physician Andrew Saal uses to orient new clinicians at the Providence Community Health Center. It’s the best I’ve seen for clinical practice. Andrew equates code choices to playing scrabble--you want to be sure you are using the boxes that give you the double and triple letter score as well as the double word score.

Welcome to the International Classification of Diseases-10! Let’s talk about Diabetes: E11.9 means diabetes without complications. If we add a system with a problem to the DM code:

--E11.2   DM with kidney

       --E11.3   DM with eye

       --E11.4   DM with nerve

       --E11.5   DM with vascular

        --E11.6   DM with other (A1c > 7.0%) we get additional points. The goal is to get the points up, as high as you can without fraud. If you add a second and third digit to the E11.6 you get:

--E11.62   DM with skin complications

--E11.620 DM with diabetic dermatitis

--E11.621   DM with foot ulcer

--E11.628 DM with skin ulcer

So if your diabetic patient has high blood pressure,high cholesterol, their HGBA1C is over 7, you should code: I10 (high bloodpressure) and E78.3 (high cholesterol) and the DM code becomes E11.65

Now to add icing to this arcane layered cake - Medicare pays more for certain combinations of codes. Hierarchical Condition Category or HCC were introduced a few years ago. Currently there are 83 HCC codes that map to over 9,500 ICD-10 codes.  But wait, there’s more – while there are actually over 68,000 ICD-10 diagnosis codes, only a fraction of them carry any HCC weight. You can probably guess what these are: congestive heart failure, diabetes,heart arrhythmias, stroke, asthma, depression, to name a few.

HCCs were developed to adjust payments in accordance with the complexity of the patient. For example, a sixty year old with high blood pressure, should be less complex than a sixty year old with high blood pressure, heart disease, and diabetes. It is called a risk-adjustment model for payment. If you add the fact that the person is homeless, doesn’t speak English,or has a learning disability it gets more complicated. Those issues are what we often refer to as social determinants of health. We should stand up and cheer, because if you care for this population, you know there are many challenges.

However, if you don’t code it right it doesn’t count. Risk adjustment drives the new physician payment models that emphasize quality instead of quantity.

Ironically, I learned even more about coding as a home visit provider for a health plan. During our webinar we were told coding is critical to preserve the prosperity of the health plan. My translation, bill Medicare for everything you can so the health plan gets as much money as they can. I even learned some new codes. Most patients with heart failure have secondary hyperaldosteronism(E26.1). If a patient has the arrhythmia atrial fibrillation (I48.0), you should add other thrombophilia (D68.69). A patient with weight loss (greater than 10% in 6 months), can have protein-calorie malnutrition at any BMI, based on nutritional status. E44.1 (mild), E44.0 (moderate).

Another difference between the health plan (HP) computer and clinic’s, is the HP’s is programed to calculate diagnoses for me, based onwhat I enter for symptoms, medications, physical findings, screening assessments for depression or falls. The clinic electronic record just isn’tthat fancy.

Secondly, in clinic our coders limit us to 4diagnoses at a time, for the health plan I often have at least a dozen. Because Medicare has amnesia (Andrew’s phrase), all codes need to be reentered annually.

The World Health Organization (WHO) copyrighted, owns,and publishes the classification ICD-10 (International Classification ofDiseases). WHO has authorized the development of an adaptation of ICD-10 for use by the US government, Medicare and Medicaid or CMS (Center for Medicare +Medicaid services). Some interesting history I didn’t know: The first international classification edition, known as the International List of Causesof Death, was adopted by the International Statistical Institute in 1893. Andfor futurists -- ICD-11 is here!!

The classification is used internationally. Here isa linkto the countries using ICD-10. We do a lot of complaining here inthe US so I asked one of my British GP colleagues about how they managed coding. Her reply:

"In General Practice (GP) here we use READ codes, introduced in 1985. They are idiosyncratic, not based on ICD-10, but crafted around diagnoses in general practice. They have been added to and modified over time. The system is complicated and about to radically change. For the last 20 years, we are paid using a Quality and Outcomes Framework-- where GPs were paid on a sliding scale for "points earned" for care of patients with specific conditions. This relied on READ coding the disease eg. heart failure, COPD , asthma, etc., but also on the measured parameters eg. BP, HBA1c and how close they were to targets. Also payment is linked to if patients attended check-ups, screenings occurred, received advice about smoking, diet etc.--all of which had to be coded. There were about 1000 different parameters measured and it was calculated on April 1st each year. GPs income depended on achieving points. Each year they added new diseases and sometimes took a few away. As you can imagine there were loads of problems with it--who decided what the points were for, and they changed each year. People gamed the system. It is criticized for not being patient centered, and if it wasn’t documented in the computer just so, it didn’t count. GPs lost income if patients didn't want to be screened, adhere to meds, accept immunizations, etc."

Sound familiar? No easy answers here, but I want my clinical EHR to do the fancy calculations that the health plan’s do. And more importantly, in this digital age, can’t we craft a computer system that keepsthe patient at the center of the interaction. Clinicians waste precious time clicking boxes and finding the right diagnoses.  

Allow me introduce Dr. Andrew Saal, a family physician and the medical director of the Providence Community Health Centers by way of several other Federal Community Health Centers (FQHC) across the country - including the one at the South Rim of Grand Canyon National Park. He understands that professionalism and well-being are closely linked for family physicians and does all he can to protect his clinicians from the non-medicine part of health care with a terrific tongue in cheek attitude.