Posted by: notdeaddinosaur | October 3, 2015

In the Trenches: Week One of ICD-10

Welcome back, blog fans. Sorry for the prolonged radio silence, but as some of you may have heard (or not, if you don’t happen to work in the medical field) this past Thursday, October 1, 2015 marked the official switch-over to ICD-10, and to say things have been a little hectic is like saying Congress is a little contentious.

What am I talking about, you say? Diagnosis coding.

At the end of my residency, the program sent the third year residents to a two-day seminar on practice management. Knowing I was about to go out on my own, I paid close attention, and ending up being able to use a great deal of what I learned. When discussing the insurance claim form, the divided it up into sections based on the “Who” (demographics, ID numbers), the “What” (procedure codes, copyrighted by the AMA, known as “Common Procedural Codes” or CPT), the “where” (to send the money: my name and address at the bottom), and of course the “why”, or the diagnosis.

Every possible thing that can conceivably go wrong with the human body can be assigned a code to identify to third payer parties the “why”* of any given medical service. Not just every disease, condition, injury, or complication, but any possible reason to go to the doctor (or in modern parlance, “to encounter the health care system”) must also be coded. Everything from a school physical to a preoperative H&P has its own code. My favorite over the years was V65.5:

Person with feared complaint in whom no diagnosis was made. Feared condition not demonstrated. Problem was normal state. “Worried well”

The system used for diagnosis coding is called the International Classification of Diseases, or ICD. Up until last week we were on version 9, which contained a total of about 14,000 codes. As of October 1, everyone switched wholesale to ICD-10.

How big a change could it be?

Pretty big.

The new set has about 68,000 codes. The vast majority of ICD-9 codes contained only numbers. Administrative codes began with the letter V, and injury codes began with the letter E. All ICD-10 codes start with a letter. Yes, they include “I”, “O”, and “Z”, which look perilously like 1, 0, and 2. Luckily they are not case sensitive, so the lower case versions may be clearer.

ICD-10 codes are super specific. One of my favorite ICD-9 codes was 729.5: “Pain in limb.” Didn’t matter which part of which limb. It was very useful. Now there are individual codes for pain, stiffness, effusion, instability, and several other derangements of shoulder, elbow, wrist, fingers, hips, knees, ankles, and toes, plus pain in upper arm, lower arm, thigh, and lower leg. AND each of the above has three subsets for right side, left side, and unspecified side.

Please don’t ask “Why?” No, a middle ear infection of the right ear isn’t treated any differently from a middle ear infection of the left ear, nor does a torn meniscus in the left knee carry any significant epidemiological difference from one in the right knee. But I’m just a tiny voice in the wilderness. All I do is actually provide medical care to real life patients, so there’s no reason for the folks on high who make “policy” to, you know, listen to people like me. At this point, if I want to get paid, I have to play along (unless I shift to a cash-only model, which I’ve decided against for the time being.)

Since I’ve always done my own coding, I’ve always had collections of “Cheat sheets”, or handy-dandy lists of frequently used codes. There’s also the Internet, which has pretty much taken the place of the huge, expensive books I had to buy every year to keep up with annual coding changes. Oh, there are books for ICD-10: an alphabetic list runs to over 1200 pages, and a tabular one (all the codes in numeric order) that runs over 1500. Luckily I downloaded them for free from CMS, and believe me, it’s so much easier to work with them as link-infested PDFs than as actual books.

You know that nightmare when you find yourself in school about to take an exam for which you never studied? That’s how I felt on Thursday morning. Actually, it was more like finding myself about to take exam for which I’d made a detailed study plan, and just started to look over the material, but hadn’t gotten around to getting everything done that I’d planned. It was scary, especially since I also had a full schedule of patients to take care of and worry about the coding later, fearing that “later” meant I wouldn’t get home until midnight. It wasn’t quite that bad, though I did find myself coding just the primary diagnosis and not adding all the other ones I usually do (to support the complexity involved in the medical decision making for a given encounter.) Also, given that it’s the start of flu shot season, there were a lot of visits just for that. And miracle of miracles! An ICD-10 simplification: there used to be a specific diagnosis for receiving the flu shot. Medicare also has another one just for receiving a pneumococcal vaccine, and a third code for receiving both. ICD-10 has just one (Z23; learn to love it.)

There’s one thing I did manage to accomplish ahead of time.Of all the various joint complaints, I chose Pain, Stiffness, and Effusion, because those are the main ones I see, and created a graphic version of the codes that roughly correspond to “Pain in Limb”: Limb pain ICD10 cheat map  Feel free to download, use, and disseminate. (Please don’t sell it. I did include a copyright notice, mainly to appease this crotchety old guy in his 80s whom I’ve known for years.)

I also did a similarly styled “Referral Cheat Sheet” for my single staffer with the codes we use most often for that other bane of our existence, insurance referrals: [insert link when I get to the office, as it’s local to that computer] and I’m currently working on a set of master cheat sheets for myself. The main one is going to end up modeled on the old superbill I used before I went electronic, but I think various skin lesions and infections will lend themselves to the mapping format quite nicely. Diabetes, though; that’s going to be a real headache. Or R51, in the new lingo.

Stay tuned, and Gd help us all.



  1. Good luck. I got in under the old system.

    Btw, Narda’s conversational hebrew may switch to evenings. Will keep you posted. Lu. good luck M


  2. This makes me love the Canadian system. I have one code that I enter for all new consults, one code for all follow ups, etc. In total, I have fewer than 20 codes that I use, and I use only about 5 on a regular basis. So much simpler!

  3. Like the cheat sheet! We have an EMR that allows us to just look for the code using natural language you just type and the choose from the codes that pop up based on the best description.

  4. Ah yes, the new coding system can be quite a burden. I read somewhere that there are two different codes to indicate whether a patient was bitten by a crocodile or an alligator. I suppose it is up to the patient to tell the doctor which aquatic reptile did the nasty deed unless of course the doctor can tell by the bite.

  5. It just sucks. The EMR isn’t very much help. The only consolation is that by the time ICD11 rears its ugly head this old woman will be retired.

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