In order for physicians and medical insurance payers to speak with each other, they have to speak in code. A physician describes what problem he treated with International Classification of Diseases (ICD) codes. In this country, we are at present using the ninth edition of these codes, ICD-9. In this, we are considered backward by much of the world, which has already moved on to ICD-10. The difference between the two is that while ICD-9 has about 13,000 codes to describe every malady that befalls our species, ICD-10 has about 68,000. This is not because there are new problems out there, it’s just that ICD-10 wants very specific descriptions of problems such as “W6113A- being pecked by a chicken,” and “V91.07XA- burn due to waterskis on fire, initial encounter.” This kind of information is very important to someone, but I don’t know who or why. American physicians have fought off the transition from ICD-9 to ICD-10 for years now, but it looks as if we will soon succumb to someone’s need for a code for “Spacecraft crash injuring occupant, initial encounter (V9542XA).” Retooling electronic health records for this transition is costing billions of dollars and is hugely unpopular with physicians, and I haven’t heard patients clamoring for it either.
But wait, there’s more: in order to get paid for his work, a physician has to use another set of codes, the Current Procedural Terminology (CPT) codes. These describe what the physician has done for the patient, and there are thousands of them as well. The rules for using them are obscure and arcane, to the extent that there are well-paid people in the medical industry, called coders, whose primary talent is sorting through them. They are critically important, because using the wrong code could lead to a physician not getting paid or, worse yet, being accused of fraud and suffering enormous penalties as a result. They are so important that they seem to be the focus of every healthcare management journal for physicians, whose articles could be summarized, “How to get paid more for the same work by the expert use of CPT codes.” I always imagined that there were similar journals for health insurance executives that read, “How to pay physicians less for their work by the expert use of CPT codes.” The image it brings to mind is of Harry Potter and Voldemort furiously slinging spells at each other.
There is an alternative to this madness. Pay your primary care physician a monthly subscription for most of your health care, so that his livelihood does not depend on filling his head with this coding nonsense. I will be happy to give my patients a diagnosis when it is appropriate, I will describe it to them in terms that are helpful, if I have time I might even look up its ICD-10 code just for the sake of curiosity. I will tell my patients what I am doing for them, because that is simply good care, and I won’t worry about whether what I am doing should be coded as counseling or toenail care (it is possible to do both at the same time). Diagnosis and billing codes in primary care serve the needs of the insurance companies, and that’s not who I choose to serve.