More baffling stuff about ICD-10 codes

The ICD-10 list may be inadequate.

ABC News reports an actor was hospitalized after his foot became caught in an elevator raising the stage during a performance of the Broadway show "Spider-Man: Turn Off The Dark."

As a connoisseur of ICD-10 codes, I decided to see if I could classify this injury correctly.

To my surprise, I could not.

The only codes having to do with elevators are the W303XXs Contact with grain storage elevator.

Since I had once read that the codes were originally developed in Europe, I even searched for "lift." But all I got were Y93F2 Activity, caregiving, lifting and W240XXs Contact with lifting devices, not elsewhere classified.

Contact with lifting devices, not elsewhere classified hardly seems appropriate for elevators, which are so common. People are frequently hurt on them or by falling down their shafts. All you get when you search "shaft" are hundreds of codes dealing with bones.

We know that ICD-10 has given us such gems as

V9027XA Drowning/submersion due to falling or jumping from burning water-skis, 

V982XXA Accident to, on or involving ice yacht,

W5609XA Other contact with dolphin,

V9542XA Forced landing of spacecraft injuring occupant and

V9733XD Sucked into jet engine subsequent encounter.

[Click on the links to read my comments about those codes.]

So how is it that there's no code for contact with an elevator? For that matter, what about injury during a Broadway show? Surely both elevator and Broadway show injuries are much more common than say V8022XA Occupant of animal-drawn vehicle injured in collision with pedal cycle.

Filippe Vasconcellos ‏(@fvguima), a Twitter follower, suggested W230XXA Caught, crushed, jammed, or pinched between moving objects, initial encounter, but it is not clear that there was more than one moving object. And the stated aim of ICD-10 is to introduce much more specificity into the codes for better tracking of things like injuries.

What we need is even more codes. Maybe we need to get going on ICD-11 sooner than we thought.

Electronic medical records: Documentation of care and upcoding

Electronic medical records make documentation easier and that may be a problem.

There are many interesting unintended consequences of electronic medical records (EMRs). I was reminded of this by a recent blog I wrote about what interns really do when they are on call. According to a study from a VA hospital using trained time-motion observers, interns spend 40% of their time on a computer and only 12% of their time taking care of patients. This meshes well with other reports noting that doctors are staring at screens instead of talking to patients.

Here’s the problem. The system actually rewards extensive documentation which may result in less patient contact. The saying “If you didn’t document it, you didn’t do it” has morphed into “Document it, and you can use a higher billing code.”

Here are some CPT billing codes for hospital visits.

99221 Initial Hospital Care, Physician spends 30 minutes at the bedside

99222 Initial Hospital Care, Physician spends 50 minutes at the bedside

99223 Initial Hospital Care, Physician spends 70 minutes at the bedside

Sources tell me that they know of physicians who never bill for less than 99223 or 70 minutes for a history and physical (H&P) examination. In order to do this the doctor must document such things as having reviewed at least 10 different systems (e.g., respiratory, GI, musculoskeletal etc.). This is easy to document without having actually done it. The EMR may have popup windows with lists of systems and symptoms that can be checked off as reviewed.

This problem is more prevalent among the so-called “cognitive” specialties like internal medicine and primary care because for procedure-based specialties like surgery, the H&P is usually “bundled” (included) as part of the fee for the surgery.

Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do.

You may think that I am exaggerating but I am not the only one to raise this issue.

A recent long-read from the Center for Public Integrity confirms my thoughts. Here’s a quote from that piece, “And Medicare regulators worry that the coding levels may be accelerating in part because of increased use of electronic health records, which make it easy to create detailed patient files with just a few mouse clicks.”

The article points out that billing for higher codes has risen over the last several years and it’s costing the taxpayers over $6 billion. It warns that Medicare audits might be forthcoming, but some feel that audits might cost more to perform than the revenue they generate.

We will see.