Postscript: What are codes for anyway?

In my last blog, my inner imp and I tussled over whether ICD-10 codes are still worth the trouble. Bottom line—they are, because codes allow us to highlight key pieces of information for the downstream users of coded data. Coding with ICD-10 is doing the best we can with what we have until the industry finds something else that works better. At the March meeting of the ICD-10 Coordination & Maintenance Committee, I was very happy to hear presenters and commenters in the audience riffing on that theme.

At the diagnosis portion of the meeting, Scott Manaker, MD, PhD and a member of the American Thoracic Society’s Clinical Practice Committee, requested early implementation of new codes to track the use of e-cigarettes (also called Electronic Nicotine Delivery Systems or ENDS) this October 1st instead of October of next year. According to Dr. Manaker, there is an epidemic in the recreational use of ENDS. Although ENDS were originally introduced as a means of quitting smoking, 19 percent of ENDS users have never been cigarette smokers. He cited recent data from the CDC showing an 11‐fold increase in ENDS use among high school students, from 1.5 percent to 16 percent in four years, and a 9-fold increase in middle school students.

The reasons he gave for asking for the new codes, and asking for them as soon as possible, were all about getting more meaningful data quickly and efficiently. He said, “New codes allow harnessing the power of the electronic health record, early identification by… practitioners, earlier tracking of outcomes. And there is no need for supercomputers to process big data, no need for genetic sequencing to achieve personalized medicine. We can achieve personalized medicine by incorporating these codes sooner rather than later.”

Later that day, there was a lively discussion about creating a code in ICD-10-CM similar to what was called the “Rehab V code” in ICD-9-CM, V57.89 Care involving other specified rehabilitation procedure. The American Hospital Association requested a new code in ICD-10 that tracks encounters for physical rehabilitation services.

In their request, the American Hospital Association said, “Hospitals and health systems have now lost the ability to track and analyze outcomes for patients receiving care for post-acute rehabilitative care…” AHA gave several reasons why it is important to distinctly identify patient encounters for rehab:

• To track outcomes of rehab therapy so the data can inform changes in patient care
• To identify patient access to inpatient rehab to see if access is adequate
• To differentiate the rehab patient population as distinct from the acute care patient population for tracking patient safety and quality indicators
• To improve providers’ overall understanding of their patients across the continuum of care

NCHS, the agency with lead responsibility for deciding whether or not to create new codes, responded that it does not support the idea, mainly because “introducing procedure-type codes into the diagnosis classification is inconsistent with development principles of ICD-10-CM.”

From the audience’s response, it was clear the public was much more interested in the practical data needs of the industry, and not too concerned about development principles of the classification. The response by coding consultant Linda Holtzman—as sharp a coding intellect as they come, and not one to mince words—was my favorite comment of the day. She supported creating a new code because there is a practical need for it. “You can take ideological purity too far,” she said.

It was wonderful to be reminded so clearly what ICD-10 codes are for, at the very meeting where the codes are created. I believe ICD-10’s future as a key healthcare transaction standard hinges on its ability to support the collection of meaningful coded data in a timely way. One of the reasons NCHS gave for NOT creating a new encounter for rehab code was this: “NCHS believes there are other options available to track and analyze outcomes for patients receiving post-acute care rehabilitation services.” When I read that statement in the C&M agenda, I thought, be careful what you wish for.

Think about it—sending providers packing without the ICD-10 code they say they desperately need is risky. On the one hand, the maintainers of the classification uphold their principles, and certainly they are entitled to them. But on the other hand? Let’s say providers are forced to find less convenient methods for tracking outcomes, patient access, and patient safety/quality for their rehab patient population. After an initial investment in developing alternative methods for creating meaningful data, let’s say they find a method that is just as convenient and works better than ICD-10. How likely are they to bother asking for a new ICD-10 code, ever? Interesting times, right?

If this isn’t already perfectly clear, let me reiterate—I’m a “bring it on, whatever works” kind of person—so if this hypothetical situation becomes real, and I get fortuneteller credit, that’s totally fine by me. ICD-10 needs to earn its keep, by providing the codes needed to produce meaningful coded data, and making those codes available at a less than glacial pace. If ICD-10 can’t be used to produce meaningful and timely data, it risks becoming the Latin of healthcare—a pithy but dead language no longer in general use—as alternative methods gain in efficiency and effectiveness. ICD-10 isn’t about the beauty and purity of a particular classification system. It’s about having the codes needed to collect good clear data, and about making those codes available in a timely way.

Rhonda Butler is a clinical research manager with 3M Health Information Systems.