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.

ICD-10 codes and politics

Senator Rand Paul has been getting some ink about a recent speech during which he mocked the Affordable Care Act for mandating the use of ICD-10 codes, some of which are pretty silly.

Theses codes are what hospitals and doctors must use when submitting bills to third-party payers.

Please understand that no one has gotten more mileage from making fun of the new ICD-10 codes than I have.

You may recall my posts on the codes for drowning due to falling from burning water skis, contact with (amorous) dolphins and getting sucked into a jet engine.

And I have to agree that the expansion in the number of codes from 18,000 in ICD-9 to over 150,000 in ICD-10 may be burdensome to most doctors.

Senator Paul is a physician, and he should know better. He is either clueless or disingenuous for blaming the ICD-10 code muddle on Obama.

As reported way back in January of 2009 by the Wall Street Journal no less, the ICD-10 codes were to be implemented by the Centers for Medicare and Medicaid Services, but CMS decided to delay doing so after protests by all sorts of medical people and organizations who said that they did not have enough time to comply.

In addition, these codes were not even developed by CMS. ICD stands for the International Statistical Classification of Diseases and Related Health Problems and the revised codes were formulated after many years of discussion by the World Health Organization (WHO).

So whether you love the new codes or hate them, they were going to be put into place regardless of the status of the ACA.

And regarding making fun of them, Mr. Paul is late to the party. My posts about the absurdity of some of the codes were on line in the fall of 2011.

Central Line Bloodstream Infections & Pay for Performance

The topic of central line bloodstream infection (CLBSI) is interesting to review because of its inclusion as one of the so-called “pay-for-performance” indicators and there is a large amount of research to look at. I want to focus on one aspect of the issue, which is the difference between information obtained from an administrative database and what is clinical valid.

Published ahead of print in the Journal of the American College of Surgeons is an article from the data mines of the Veterans Administration showing that some 63% of CLBSIs seen at VA hospitals over a 5 year period were actually coded incorrectly. They were falsely positive; the patients did not have CLBSIs.

You might wonder, “How can this be?”

Here’s how. When scrutinized carefully by clinician chart review, 27% had thrombophlebitis at a peripheral IV site, 7% had infected surgically placed arterial graft infections and 6% had cellulitis at an IV site that was not a central line. The rest of the false positives were as follows: chart coded as having a CLBSI when the work-up was actually negative for infection; the patient had no evidence of ever having had a central line; the patient had a CLBSI that was present on admission to the hospital and therefore not preventable during the admission being reviewed.

The problem is that the ICD-9 codes used during the study period (2003-2007) were not specific enough. New codes have been developed but are still not suitable as justification to withhold money from hospitals.

The paper also points out that the CDC has published three different sets of criteria for determining whether a central line is infected.

ICD-9 codes were created for billing purposes, not for studying clinical problems. They are also subject to coding errors as the paper clearly depicts. This is one of a number of papers that illustrate the problems associated with the use of administrative data in analyzing clinical problems.

I’m not necessarily against the pay-for-performance concept, but it must be based on accurate data.

What do you think about "pay-for-performance"?

This post appeared on Sermo yesterday and 84% of those physicians voting did not favor the use of pay for performance.

Does Oral Contraceptive Use Increase Rates of Prostate Cancer? I Doubt It.

A recent paper linking the use of oral contraceptives by women to higher rates of prostate cancer in men has received some media attention. Two urologic oncologists from the University of Toronto in Canada published this hypothesis in an open access journal, BMJ Open. The full text is available here.

The paper’s plausibility is based on some previous work suggesting the exposure to estrogen might increase the risk of prostate cancer.

The study was done using retrospective data from various sources. Information on contraceptive use and prostate cancer was obtained for countries with all levels of economic development on all continents. The main finding was that oral contraceptive use was associated with both the incidence of and mortality from prostate cancer, while all other types of contraception showed no such association.

A fair amount of statistical manipulation was used to generate the results. When one first reads the paper, it is almost believable until one reaches the section postulating the mechanism by which this association could possibly be real. The means by which oral contraceptive use could affect prostate cancer rates is posited as increased levels of so-called endocrine disruptive compounds (in this instance, estrogens) in drinking water secondary to excretion by women.

To their credit, the authors themselves admit that the paper has some serious limitations.

Obviously, more developed countries would have higher rates of cancer screening and detection. Rates of prostate specific antigen (PSA) testing were not available. The authors felt that their method of controlling for gross domestic product obviated the need to have actual PSA screening data.

The authors further concede that there are no available data on the levels of endocrine disruptive compounds in the drinking water of a single country.

As a mere general surgeon with no ecologic or public health credibility but having seen the vast reservoirs of drinking water in my area, I find it difficult to believe that there could be significant levels of endocrine disruptive compounds in the public water supply. And what about the fact that in many highly developed countries, people drink bottled water presumably free of endocrine disruptive compounds?

An [assumed] editorial summary of the paper states “This study is an ecological study and thus has significant limitations with respect to causal inference.” Translation: There is absolutely no proof that oral contraceptive use in women causes higher rates of prostate cancer in men.

Bottom line: I’m not going to stop drinking water. Are you?

They get it right! ICD-10 Code W5609XS Other contact with dolphin, sequela

The ongoing saga of the new International Classification of Diseases, 10^th revision [ICD-10] continues. ICD-10 is what every physician and hospital must use when submitting bills to various third parties. The list of codes has been expanded from 18,000 to 140,000 and some of them defy description. See other posts about getting sucked into a jet engine and drowning having fallen off burning water-skis.

In today’s episode, we investigate W5609XS Other contact with dolphin, sequela. Since this is listed as “other contact,” you may be wondering what the specific codes might be. They are as follows

W5601XA Bitten by dolphin, initial encounter

W5601XD Bitten by dolphin, subsequent encounter

W5601XS Bitten by dolphin, sequela

W5602XA Struck by dolphin, initial encounter

W5602XD Struck by dolphin, subsequent encounter

W5602XS Struck by dolphin, sequela

Having eliminated bitten or struck, I thought I was left with only my imagination to envision what “other contact with dolphin” might be. What other contact with dolphin could there be? Why would the folks at ICD-10 headquarters have put in such a code? Well, apparently they did their homework on this one.

In 2002, CNN reported that a dolphin was attempting to sexually assault female bathers on the south coast of England. A noted dolphin wrangler was unsuccessful in to trying to lure the dolphin to France. [It's unclear why France was the destination. It be related to the fact that's it's also the home of Dominique Strauss-Kahn, another alleged sexual predator.]

But the other side of the story is the recent news that a man named Malcolm Brenner has written a book about his 9-month long sexual relationship with a dolphin. The book, entitled Wet Goddess: Recollections of a dolphin lover, tells the story of his affair with “Dolly,” who interestingly is portrayed as the aggressor in the relationship. There is also a website devoted to this story. T-shirts and posters are available should you be so inclined.

Somewhat off point, but nonetheless amusing, is the unfortunate juxtaposition of an ad on Amazon.com’s page describing Wet Goddess. Just above the details about how to purchase the book is information on how you can buy a case of Chicken of the Sea Tuna, new or used [sic] for only $39.84.

You may recall that dolphins are known to swim with tuna and are often caught by commercial fishermen. There is controversy about the fate of dolphins ensnared in this way. Ironically, Amazon purchasers of both the book and the bargain tuna might be reading about Dolly and eating her at the same time.

You cannot make this stuff up.

ICD-10 Codes: V97.33XS Sucked into jet engine, sequela

In an effort to expand the International Classification of Diseases [ICD] codes to be all-encompassing, the new ICD-10 list includes many new diseases and injuries. We have already reviewed code "V9027XA Drowning and submersion due to falling or jumping from burning water-skis, initial encounter" and found it difficult to imagine a scenario in which water-skis ignite.

Here is another code that at first seems to be a bit of a stretch, "V97.33XS Sucked into jet engine, sequela." One would think that the only sequela of someone being sucked into a jet engine would be hamburger. 

However, here is video evidence of one of the luckiest guys on earth. A Navy crewman was preparing an attack jet for take-off from an aircraft carrier when he was ingested by one of its jet engines. Miraculously, he survived with only a few scratches.

On the other hand, surviving having been sucked into a jet engine is a relatively rare event. Do we really need a code for this?

ICD-10 Codes: "Drowning and submersion due to falling or jumping from burning water-skis"

The Centers for Medicare and Medicaid Services [CMS] have just released the updated version of the medical coders’ bible, the International Classification of Disease, 10^th Revison [ICD-10]. The long-awaited revision is much more detailed than previous versions, going from 18,000 codes in ICD-9 to 140,000 codes in the new release.

In an attempt to achieve greater specificity for describing diseases and injuries, the authors came up with some curious items. There are probably some other howlers, but so far, the winner is “V9027XA Drowning and submersion due to falling or jumping from burning water-skis, initial encounter.” There are also codes for subsequent encounters and sequela of drowning and submersion due to falling or jumping from burning water-skis.

I have been wracking my brain all weekend to come up with a plausible scenario in which a person could drown and  be submerged while falling or jumping from burning water-skis.

Can water-skis be set afire? It’s hard to say. According to Trails.com, they are most commonly made of a combination of fiberglass and graphite. I suppose they could be burn under certain conditions but I really don’t see how they could be ignited during normal use because, of course, they would be in the water.

One way that I could envision anyone falling or jumping from burning water skis is if that person were to water-ski through a burning oil slick. And even then, it’s hard to see how the skis would catch fire as the skier would be moving fairly quickly. Furthermore, why would one deliberately water-ski through a burning oil slick? Not only would he have to fall or jump off, he would also have to drown and be submerged.

I have come up with an answer. Someone, possibly an actor from the Jackass series of movies, sets up his water skis on milk crates in the back yard. The skis are positioned over a kiddie pool. He mounts the water skis while an accomplice sprays them with gasoline. The skis are lit, and the man jumps or falls from the burning skis, submerging and drowning himself in the process. Luckily there is an ICD-10 code for that.

While we’re on the subject, how does one have subsequent visits after drowning? Once one drowns, he is dead. I believe charging for subsequent visits would possibly be considered fraud. The only sequela of drowning that I am aware of is a funeral.

I wonder if there are codes for jumping or falling from burning snow skis?