My Interstellar Neurosurgical Patient

 

“That’s the first time I’ve seen that diagnosis!”

I looked up at the electronic chart the resident had loaded on our workroom monitor.  Sure enough, the patient’s problem list included ICD-10 code V95.43XS: “Spacecraft collision injuring occupant, sequela.”

“He’s an astronaut?” I asked, hopefully.

“No, I don’t think so” the resident responded, “he appears homeless.  And high.”

I was disappointed, my hopes that we had admitted a space traveler to our service overnight were dashed.  Instead, the diagnosis was clearly a case of clerical error, a byproduct of a cumbersome and onerous diagnosis system forced upon healthcare providers.

For a hospital or physician to bill for services, the Center for Medicare and Medicaid Services (CMS) requires both a diagnosis and a procedure.  These are both assigned alphanumeric codes: Diagnosis codes come from the International Statistical Classification of Diseases, 10th revision (ICD-10) codes, developed by the World Health Organization.  Procedure codes come from Current Procedural Terminology (CPT) codes, developed by the American Medical Association.

Every time a physician writes a clinical note, performs a procedure, orders a test, or has any sort of patient encounter, the electronic medical record (EMR) asks for an ICD-10 code.  Go to a primary care office, and the doctor will want to bill for every issue discussed that day, so multiple ICD-10 codes will be entered.

The ICD-10 coding system is so specific and complex that multiple different codes exist for similar problems.  The primary care physician might simply put in M54.9 (back pain) but when they come see me, the neurosurgeon, I know to put in M48.061 and M54.16 (lumbar spinal stenosis without neurogenic claudication but with radiculopathy).  I could probably add in M51.16 (displacement of lumbar intervertebral disc with radiculopathy) as well.  Of course, I’m not going to go through the trouble of deleting the primary care doctor’s initial assessment.  He had written notes associated with it.  Now the patient’s problem list has four items listed for one issue.

He might be a new patient to our clinic, so I would like to add his diabetes to the problem list.  I can’t just add E11.9 (diabetes), as that is far too generic for our EMR, so popup boxes appear after I select “diabetes.”  What type of diabetes, how long has the patient been on insulin, what are their complications, how severe is their retinopathy and/or kidney disease?  In all, there are 58 different boxes (I counted) to click through to get the “accurate” diabetes diagnosis.  Of course, being a neurosurgeon, I have no clue about this patient’s diabetes complications or retinopathy.  Information on differing insulin types left my brain long ago.  So I click through as best I can.  After a few frustrating seconds, I arrive at Z79.4.  I’m sure his primary care provider will come up with a much more accurate and detailed ICD-10 code which will join my Z79.4 on the patient’s problem list.  The same must be done for his hypertension, headaches, acid reflux… Eventually, I just give up.  His problem list already takes up the entire page.  I don’t envy those poor primary care doctors.

The complexity of the ICD-10 coding system clearly explains how our homeless gentleman received a NASA-related diagnosis.  Some provider, likely rushed for time, was clicking through and simply chose the wrong code.  An encounter with extraplanetary craft is not the only obscure condition enshrined with its own ICD-10 code.  If one is trying to enter a bone marrow disorder, one might mistakenly click on W61.111XA (bitten by macaw).  Perhaps a problem with fluid retention is mistaken for V91.07XD (burn due to water-skis on fire, subsequent encounter).  Of course, if a physician is ever searching for a code to use, there’s always Z63:1 (problems in relationship with in-laws).

But, no, alas our poor homeless man just had Z59.0 (homeless single person) and F15.929 (methamphetamine intoxication, not to be confused with F15.10 [methamphetamine abuse] or F15.11 [methamphetamine use disorder, early remission]).  I still haven’t had the pleasure of treating an astronaut.

Published in Healthcare
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  1. Arahant Member
    Arahant
    @Arahant

    Thanks for this insight into what doctors have to put up with.

    • #1
  2. JoelB Member
    JoelB
    @JoelB

    No wonder things get fouled up.

    • #2
  3. Mark Camp Member
    Mark Camp
    @MarkCamp

    Doc,

    If this software didn’t meet customer requirements, it would get fixed.  So it must meet customer requirements.

    The problem with the product from the point of view of the doctor and ultimately the patient derives entirely from the fact that they are no longer the customers.  The bureaucracy of socialized medicine is now the customer.

    The doctor and patient are consumable supplies.

    • #3
  4. Kozak Member
    Kozak
    @Kozak

    The high precision ICD 10 coding system that was driven to a large part by academics and government so they could mine endless data is a classic example of

    ”Garbage In Garbage Out”

    • #4
  5. MarciN Member
    MarciN
    @MarciN

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    • #5
  6. Mark Camp Member
    Mark Camp
    @MarkCamp

    MarciN (View Comment):

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    That is the next step in the march toward socialist totalitarianism.  It’ll be here soon enough and you won’t like it.  So don’t ask for it.

     

    • #6
  7. JosePluma Thatcher
    JosePluma
    @JosePluma

    Arahant (View Comment):

    Thanks for this insight into what doctors have to put up with.

    They just updated our intake forms, so nurses now also have to experience the joys of dealing with ICD10. 

    • #7
  8. Arthur Beare Member
    Arthur Beare
    @ArthurBeare

    You MDs out there; is this satire?Are the codes given in the post for real?

    • #8
  9. Sandy Member
    Sandy
    @Sandy

    The stories behind some of those codes must be interesting. Is there something different about a bite from a Macaw that makes having a separate code sensible or was someone fooling around that day?  Or Z63:1 on in-law troubles. What pestered daughter or son-in-law wrote that one?  And what insurers cover it I’d like to know!  

    • #9
  10. Arahant Member
    Arahant
    @Arahant

    Arthur Beare (View Comment):

    You MDs out there; is this satire?Are the codes given in the post for real?

    Here’s the database, look ’em up.

    https://www.icd10data.com/ICD10CM/Codes/

    • #10
  11. Arahant Member
    Arahant
    @Arahant

    https://www.icd10data.com/ICD10CM/Codes/V00-Y99/V95-V97/V95-/V95.43XS

    • #11
  12. Kozak Member
    Kozak
    @Kozak

    Arthur Beare (View Comment):

    You MDs out there; is this satire?Are the codes given in the post for real?

     

    Here’s some for Suicide by Bee

     

    • #12
  13. Dr. Craniotomy Coolidge
    Dr. Craniotomy
    @Craniotomy

    Arthur Beare (View Comment):

    You MDs out there; is this satire?Are the codes given in the post for real?

    Yes!  I have achieved Poe’s law!

    • #13
  14. aardo vozz Member
    aardo vozz
    @aardovozz

    Arthur Beare (View Comment):

    You MDs out there; is this satire?Are the codes given in the post for real?

    You can google ICD-10 and look for yourself. And yes, they are. 🤯

    ( And beaten to it once again. I’m having a slow, slow week 🤦‍♂️🤦‍♂️🤦‍♂️)

    • #14
  15. Basil Fawlty Member
    Basil Fawlty
    @BasilFawlty

    Classification. It’s making me hate.

    • #15
  16. Mark Camp Member
    Mark Camp
    @MarkCamp

    Basil Fawlty (View Comment):

    Classification. It’s making me hate.

    Basil,

    I think I understand.

    But til now I always knew.

    • #16
  17. Metalheaddoc Member
    Metalheaddoc
    @Metalheaddoc

    Yeah. Lots of crazy codes. Gored by bull. Injury by spacecraft, etc. I think the purpose of the injury codes was for data gathering regarding accidents and various traumas.

    But every iteration of ICD and CPT codes get more complex, not simpler. I think there is a whole government-coding-insurance-industrial complex behind this. 

    Bureaucrats get paid to make it. 

    Teachers get paid to teach it. 

    Coders get paid to apply it.

    Consultants get paid to make sure coders applied it maximally. 

    Insurance goons get paid to deny it.

    Doctors don’t get paid, if at all possible. 

    =PROFIT!

    • #17
  18. Jules PA Member
    Jules PA
    @JulesPA

    Does Siri work with this mess of a coding system?

    “Siri I have a headache.”

    ICD code z99.7 entered too many cpt codes. Initial

    ICD code z99.8 entered too many cpt codes. Subsequent

    ICD code z99.8 entered too many cpt codes. Repeated

    ICD code z100.0 entered too many cpt codes. Terminal

     

    • #18
  19. Dr. Craniotomy Coolidge
    Dr. Craniotomy
    @Craniotomy

    Jules PA (View Comment):

    Does Siri work with this mess of a coding system?

    “Siri I have a headache.”

    ICD code z99.7 entered too many cpt codes. Initial

    ICD code z99.8 entered too many cpt codes. Subsequent

    ICD code z99.8 entered too many cpt codes. Repeated

    ICD code z100.0 entered too many cpt codes. Terminal

     

    Ironically that’s one of my big gripes with the whole mess!  If my Amazon Alexa can spy on my conversations to tailor my ads, can the same AI please be used to code patient diagnoses without having to make me click so many darn buttons?

    • #19
  20. Gazpacho Grande' Coolidge
    Gazpacho Grande'
    @ChrisCampion

    Arthur Beare (View Comment):

    You MDs out there; is this satire?Are the codes given in the post for real?

    You don’t have to be an MD to recognize the codes, it’s out there on the interwebs.

    https://www.icd10data.com/ICD10CM/Codes/Rules/Billable_Specific_Codes/727

    Oh, look – while a nuclear war is going on, you can be sure you’ll have guidance as to correct coding:

    • #20
  21. Gazpacho Grande' Coolidge
    Gazpacho Grande'
    @ChrisCampion

    Metalheaddoc (View Comment):

    Yeah. Lots of crazy codes. Gored by bull. Injury by spacecraft, etc. I think the purpose of the injury codes was for data gathering regarding accidents and various traumas.

    But every iteration of ICD and CPT codes get more complex, not simpler. I think there is a whole government-coding-insurance-industrial complex behind this.

    Bureaucrats get paid to make it.

    Teachers get paid to teach it.

    Coders get paid to apply it.

    Consultants get paid to make sure coders applied it maximally.

    Insurance goons get paid to deny it.

    Doctors don’t get paid, if at all possible.

    =PROFIT!

    Well, maybe profit.  Certainly new administrative costs for the hospital to seek recovery on, in whatever rate increases its allowed to submit to state approving boards. 

    • #21
  22. Z in MT Member
    Z in MT
    @ZinMT

    Ironically, the codes reduce accountability rather than increase it. It is the same story as any bureaucracy – if you make the system complex enough nobody can be held accountable. They did their job, they clicked the boxes, and sent it up the line to the next of 8 people that click the box without really looking at it.

    It is like purchasing systems for large companies or governments, since 8 people have to sign off on a purchase, none of the 8 people can held accountable for that purchase.

    • #22
  23. Nanocelt TheContrarian Member
    Nanocelt TheContrarian
    @NanoceltTheContrarian

    One of the features of the ICD codes is that they change them completely from time to time. The ICD-10 iteration was mandated several years ago. Prior to that, we used ICD-9 codes. The coding systems, ICD-9 vs ICD-10 are completely different. No real reason was ever given for a wholesale change in the codes. Maybe it had something to do with computer systems. I for one have no idea why the change. The ICD-9 coding system had been in place for many years. After long use, I had pretty  much all of the codes that I could ever use committed to memory, so it was a quick and easy process for me to select an ICD-9 code. Given my age and lack of enthusiasm for coding, I have a hard time remembering the ICD-10 codes.  The EHR that our oganization uses is abysmal when it comes to looking up codes and as others here have noted, the process is time consuming and frustrating. I find it much easier to simply google the specific diagnosis adding ICD-10, then entering the alpha-numeric code that pops up into the EHR.

    I just tried asking Alexa for the ICD-10 codes for a couple of diseases, and Alexa gave me the codes!!!

     

     

    • #23
  24. Arahant Member
    Arahant
    @Arahant

    Nanocelt TheContrarian (View Comment):
    I just tried asking Alexa for the ICD-10 codes for a couple of diseases, and Alexa gave me the codes!!!

    Okay, now that is funny.

    • #24
  25. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    MarciN (View Comment):

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    Move to a cash only system?

    A lot of doctors won’t accept Medicaid.

    I’ve also heard of geriatricians also moving to cash because Medicare payouts are low.  The 80/20 rule in Medicare is a lie.

     

    • #25
  26. Dr. Craniotomy Coolidge
    Dr. Craniotomy
    @Craniotomy

    MISTER BITCOIN (View Comment):

    MarciN (View Comment):

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    Move to a cash only system?

    A lot of doctors won’t accept Medicaid.

    I’ve also heard of geriatricians also moving to cash because Medicare payouts are low. The 80/20 rule in Medicare is a lie.

     

    There’s no question we need some sort of safety-net system.  I work for the county hospital now.  None of my patients can afford a cash pay physician.  They are all on food stamps.  I just wish we could fund a safety net without all the clerical BS.  

    • #26
  27. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Dr. Craniotomy (View Comment):

    MISTER BITCOIN (View Comment):

    MarciN (View Comment):

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    Move to a cash only system?

    A lot of doctors won’t accept Medicaid.

    I’ve also heard of geriatricians also moving to cash because Medicare payouts are low. The 80/20 rule in Medicare is a lie.

     

    There’s no question we need some sort of safety-net system. I work for the county hospital now. None of my patients can afford a cash pay physician. They are all on food stamps. I just wish we could fund a safety net without all the clerical BS.

    Hospitals were originally established as a non profit charity organization relying on donors?

     

    • #27
  28. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Dr. Craniotomy (View Comment):

    MISTER BITCOIN (View Comment):

    MarciN (View Comment):

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    Move to a cash only system?

    A lot of doctors won’t accept Medicaid.

    I’ve also heard of geriatricians also moving to cash because Medicare payouts are low. The 80/20 rule in Medicare is a lie.

     

    There’s no question we need some sort of safety-net system. I work for the county hospital now. None of my patients can afford a cash pay physician. They are all on food stamps. I just wish we could fund a safety net without all the clerical BS.

    Maybe you can barter with your poor patients?

     

    • #28
  29. Mark Camp Member
    Mark Camp
    @MarkCamp

    Dr. Craniotomy (View Comment):

    MISTER BITCOIN (View Comment):

    MarciN (View Comment):

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    Move to a cash only system?

    A lot of doctors won’t accept Medicaid.

    I’ve also heard of geriatricians also moving to cash because Medicare payouts are low. The 80/20 rule in Medicare is a lie.

     

    There’s no question we need some sort of safety-net system. I work for the county hospital now. None of my patients can afford a cash pay physician. They are all on food stamps. I just wish we could fund a safety net without all the clerical BS.

    There is no question in your mind that a free people cannot survive, and no question in mine that they not only survive, but live better the more free they are.  I can prove my thesis, and I can prove yours wrong.

    • #29
  30. Dr. Craniotomy Coolidge
    Dr. Craniotomy
    @Craniotomy

    Mark Camp (View Comment):

    Dr. Craniotomy (View Comment):

    MISTER BITCOIN (View Comment):

    MarciN (View Comment):

    There are too many people involved in and running the healthcare system who wouldn’t know how to treat anyone for anything.

    Doctors and nurses and physicians’ assistants have my sympathy.

    Maybe you should all go on strike. I see no other way to shake some sense into the business side of the system.

    Move to a cash only system?

    A lot of doctors won’t accept Medicaid.

    I’ve also heard of geriatricians also moving to cash because Medicare payouts are low. The 80/20 rule in Medicare is a lie.

     

    There’s no question we need some sort of safety-net system. I work for the county hospital now. None of my patients can afford a cash pay physician. They are all on food stamps. I just wish we could fund a safety net without all the clerical BS.

    There is no question in your mind that a free people cannot survive, and no question in mine that they not only survive, but live better the more free they are. I can prove my thesis, and I can prove yours wrong.

    I would love to hear more.  Even Hayek endorsed basic safety net services.  

    • #30