ICD-10 Keeps Getting More Painful

As I previously discussed,  a year ago we transitioned from the disease classification ICD-9 to ICD-10. That has been painful, but they keep making tweaks that require more work.

I guess the powers that be decided that more than 155,000 diagnoses were not enough when they recently changed many diabetes diagnoses (a day or two ago, at least, my organization implemented the latest edition). Now it’s no longer sufficient to say that someone has Type 2 Diabetes Mellitus with Diabetic Neuropathy [E11.40], for example, but I now have to specify in addition whether it’s with or without long term insulin use, or if it’s unspecified. That means all my carefully constructed Problem Lists on my patients no longer work. Every diabetic medication I reorder will have to be changed as they are associated with a diagnosis.

Across all my patients I’d estimate that’s close to 1000 changes I will need to make. Assuming it takes me 30 seconds each time (I’m probably a lot faster than most of my colleagues) that’s over 8 hours, so a full work day. Multiply that across all the primary care doctors and that’s a lot of time – about 1000 people working years! We have a shortage of primary care physicians and I think there are many better ways to spend our time.

I typed “type 2 diabetes mellitus” into my electronic medical record. I eventually scrolled to the bottom to see a message that there were 3158 diagnoses loaded, but that the results had been limited due to it being a common phrase! Many of these were synonyms, and one can save favorites, but I think it’s ludicrous that we have so many codes for just one disease. Those who promulgated moving to ICD-10 claimed the higher specificity would lead to all kind of advantages by being more precise, but in reality physicians can’t spend all day just to pick a diagnoses and they are going to pick something close that will satisfy the billing system. For many diagnoses you can’t even get precise agreement. There are various codes for uncontrolled diabetes, for example, but if you ask different doctors what that means, you’ll get different answers.

Patients with diabetes have to suffer from complications of their disease, increased medical costs, and being stuck more often for blood or injections. It’s too bad their physicians have to suffer more as well.

Author: Daniel Ginsberg, MD, FACP

I'm an internal medicine physician and have avidly applied computers to medicine since 1986, when I wrote my first medically oriented computer programs. So yes, that means I'm at least 35-years-old!

5 thoughts on “ICD-10 Keeps Getting More Painful”

  1. Totally agree with this observation regarding Type 2 diabetes and use of insulin or not, although I’m not sure whether it’s an ICD10 issue or an Epic issue. Ironically, at about the same time, the need to clarify between 3 levels of “essential hypertension” disappeared — (one less click, hooray!). We’re back to just good old “essential hypertension.” This change for the good feels like a response to complaints. Then there are numerous decisions to make about subjects such as GERD “with” or “without esophagitis.” There is value in keeping many diagnoses vague because clinical judgment can be astute but clinicians can’t magically know details regarding esophageal inflammation without an EGD.

    One can discern committee work behind many of these diagnostic tableaus, much of it not science based. There is so much detail packed into the diabetic options that it becomes laughable. Consider just neuropathy in this setting: how many choices? Polyneuropathy, mononeuropathy, autonomic neuropathy? There must be 15 different choices with the most basic and common “peripheral neuropathy” lacking. Clearly neurologists on the committee argued against the vagueness and commonness of the terminology, so we’re left with an array of definitions likely open to testy debate at a forum.

    It would be nice to know who is ultimately responsible for making the “insulin or not” changes in the diagnostic platforms, and whether they understand the time sucking tyranny of clicks. For each increase of one click, there should be a demerit for the administrator ok-ing it; conversely a bonus for reducing clicks. But none of us have the time to track this down…

    1. Thanks for your comments, I completely agree. I’m not sure where the changes are made, but I don’t think it’s Epic. I believe it’s a 3rd party that comes up with the various descriptions, though it’s presumably based on the committee decisions. I’ve found the diabetic neuropathy description to be a problem as well, usually not knowing of several is the correct choice. So the neurologists may have precise definitions, but the majority of the people choosing the codes are probably practically flipping a coin. Another code that a problem is Barrett’s Esophagus. The only options are without dysplasia, with low grade dysplasia, with high grade dysplasia, and with dysplasia of unspecified degree. What are we supposed to choose if we don’t know whether or not there is dysplasia? There is also no glaucoma, unspecified. I usually don’t know if it’s open or closed angle, etc.

  2. I subscribe to the garbage in garbage out theory when it comes to this. The most generic, least informative diagnosis that gets me through the check gates is the one I routinely use. (Example: Allergic rhinitis other, rather than one of the 30 choices available…..) Sigh. No one is paying you for your time trying to enter the ‘most accurate’ choice, and the specificity is very rarely helpful clinically. I just need to know you have chronic sinusitis, not chronic ethmoid, maxillary, sphenoid, frontal, or pan sinusitis…. Which reminds me to try using chronic pan sinusitis as a single code for my next multiple sinus FESS……

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