Building a Better Health Care Dictionary

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Although the United States does not have the world’s best health outcomes or the most cost effective care, we still lead the world in medical innovation. American researchers and companies dominate fields like drug development and medical devices. There’s no better sign of how quickly U.S. medical technology and technique evolves than the upcoming transition to a new system of diagnostic and procedures codes used to document care.

Beginning in October 2014, the federal government will require health care providers to use a much bigger set of some 155,000 medical codes to document patient conditions and treatments, an enormous leap from the one now in use, which includes less than 20,000. “Medicine has exploded in terms of technology and language and we have to be able to keep up,” says Ricardo Martinez, an emergency room doctor at Grady Memorial Hospital in Atlanta and a consultant to large hospitals transitioning to the new code system.

The increasing complexity and high-tech nature of American medicine has coincided with an explosion of something else as well—cost. Health policy experts say because U.S. doctors and hospitals are generally paid for every individual test and procedure performed, there is sometimes a bias toward advanced technology, which is more expensive. Payments are determined based on codes submitted to insurers.

The new medical code system, known as ICD-10, was developed by the World Health Organization in the early 1990s and has been in place in other countries for years. The U.S. lags behind because our version of ICD-10 is more complicated, in part, due to our chaotic payment system, which includes thousands of insurers paying. (This is in contrast to many European countries where private insurers are highly regulated and fewer in number.) “We had all these payers and medical associations involved, so making U.S. version took longer,” says Martinez. The basic WHO version of ICD-10 includes a fraction of the codes that will be used in the U.S. iteration. The WHO, in fact, is already hard at work on ICD-11.

While the complicated nature of ICD-10 illustrates the American health care system’s bias toward advanced and complex medical care, adopting the new system could save money and improve quality, according to Martinez. The current system, ICD-9, for example, doesn’t include different codes for treatments and diagnosis on the left and right sides of the body. Such information can be vital to evaluating a patient with a history of stroke or even knee surgery—especially if a patient is unable to explain his or her medical history. ICD-10 will greatly increase the number of codes that apply to specialties that have advanced significantly since 1979, when the U.S. adopted ICD-9, like orthopedics and cardiology.

It’s difficult and expensive to switch over to a new code system, which is why the American Medical Association and some other doctor groups have resisted adopting ICD-10. (The AMA estimates converting to ICD-10 could cost $83,000 to $2.7 million per physician practice, depending on its size.) The AMA backed legislation introduced in Congress to scrap implementation of ICD-10 altogether, although the Department of Health and Human Services says this is a non-starter. Part of Martinez’s job is winning physicians over. “Right now, they just see it as a burden instead of a benefit,” he says. “But unless you have better information that’s more descriptive, you’re always going to be at a loss to provide better care.”

Martinez says his pitch to resistant doctors and hospitals is that the new code set will allow for better collection and analysis of data that can improve health care quality and save money. The Affordable Care Act encourages adoption of new payment systems that base reimbursement on overall health of patients, instead of separate payments for every procedure and treatment. This move will make ICD-10, being put in place alongside new electronic health records systems nationwide, a useful tool.

Martinez says with ICD-10, physicians will be better able to more accurately track which patients are sickest and most expensive to treat. This tracking, made possible by more distinct codes, will allow physicians to focus more attention on the neediest and costliest patients. “As a physician, you want to manage risk,” says Martinez. “As we move away from getting paid for every little thing we do, I think ICD-10 is going to be like gold.”