What’s Coming in Healthcare Reform in 2014?

My middle daughter is a graduate student in opera at Eastman School of Music. After October 1, if I go to hear her sing in an opera and get injured while there, a specific code must be used if my healthcare is to get paid. That code is Y92.253: “Opera house as the place of occurrence of the external cause.”

Perhaps I will be at Ellen Trout Zoo and get “Bitten by turtle, initial encounter” (W5921XA). And if, for some reason, I am stupid enough to get injured again by said turtle, there is a code for that, too:  “Struck by turtle, subsequent encounter” (W5922XD). But the current favorite new code among pundits has to be V9027XA: “Drowning and submersion due to falling or jumping from burning water
-skis, initial encounter.” Really? Who comes up with this? Is this a sick joke?

Our current system of coding for clinical encounters in healthcare is ICD-9, which has been in use since 1979. ICD-9 contains around 13,000 diagnosis and 3,000 procedure codes, arguably more than we need already. But get ready, because ICD-10 jumps to 68,000 diagnosis and 72,000 procedure codes, including the ridiculous ones noted above.

The change to ICD-10 illustrates the problem of government involvement in healthcare. First, complexity increases exponentially while usefulness – what I call the common sense factor – plummets. Then, the government tightens the rule belt, so that if you do not code correctly (how did I know you were bitten by a turtle before!), you do not get paid. Not only that – and this is what really galls me – if you don’t do it correctly, as narrowly and obscurely defined as only the federal government can do it, it is labeled fraud and abuse.

Someone asked me, as I explained this to them, “How will the government know if you didn’t do it correctly?”

Simple. They contract out to firms that employ high school-educated workers to go out and look for “fraud and abuse”. These firms get paid for what they find – whether or not what they find is really accurate – and then the government takes back those “fraud and abuse” payments from the provider (the doctor or the hospital, for example). Then, the provider has to fight multiple levels of appeal in order to get their money back, if they can afford the appeal process.

This is how our federal government is “saving money” with healthcare reform: make the hoops impossible to jump through; only pay you if you manage to make it through the hoop; then take back what they pay you because someone else with an unfair incentive claims you didn’t really make it through the hoop after all.

Our healthcare system truly needs to be reformed, but so far, very little is happening that gives me hope that we are headed the right direction. I foresee an explosion of job opportunities starting October 1, and anyone with expertise with how to code under ICD-10 will be golden. Orthopedic surgery, for example, will see one code under ICD-9 – 821.01 Fracture of femur, shaft, closed – expand into at least twenty four possible codes under ICD-10, depending on laterality, displaced or non-displaced, location, fracture type (greenstick, comminuted, transverse), type of healing (routine, delayed, non-healing), malunion, nonunion, open or closed, and encounter type (initial or subsequent). Those who can play the game successfully will survive.

At a time when payment for healthcare services needs simplification, we are taking a major step in the wrong direction. Now, is that step left, or right? There’s probably a code for that.