CMS setting itself up for billions of dollars of wasteful spending in ICD-10

Sometimes people do their homework with setting up a new system, and sometimes they don't. Sometimes they do their homework, but not enough of it, and billions of dollars of wasteful spending occurs that could be avoided. But "they" won't listen.

 

This has happened for decades with ICD-9-CM. Through persistence of outside sources, some corrections got made in ICD-9-CM, and some are in the planning phase to be corrected in ICD-10. One particular concept, however, started in ICD-9-CM and is expanded in ICD-10—and it will cost the taxpayers and the Medicare program billions of dollars. This waste could be prevented. But "they" won't listen.

 

The concept is pulmonary insufficiency. In ICD-9-CM, we had three codes:

Respiratory insufficiency is a symptom of who knows whatever condition a patient may have that needs workup and definition.

 

The fact is that pulmonary insufficiency has no definition other than the implication that the lungs aren't doing all they should—strictly speaking, it means not clearing carbon dioxide from the blood adequately. It is unmeasurable and indefinable. It is open to wide interpretation and means absolutely nothing as a diagnosis. Yet both 518.82 and 518.52 fall in the same category as acute respiratory failure, whether due to disease or due to trauma and surgery—and these are both measurable and definable and recognized conditions by anyone who treats patients, old and young.

 

The numbers are there, and you'd better meet the criteria in order not to be accused of unethical coding and billing. But insufficiency is a vague term that has no meaning to anyone and is worthless in the practice of medicine other than telling someone to look for a disease.

 

Giving "acute respiratory failure" some statistical pertinence and appropriate reimbursement for treating it makes sense, both for the physician who is actually evaluating and treating the patient and the facility in which that treatment is being rendered. Giving "other pulmonary insufficiency" similar consideration is a joke.

 

CMS has been told this over and over for the past 10 years, and they won't do anything about it. The National Center for Health Statistics has been told about this for the past 10 years, and they won't do anything about it either.

 

Why? Maybe because they made the mistake in 1989 when the code set was invented and in 1998 and 2011 when the code sets were expanded, and they'd be embarrassed to admit their error. Nothing else makes sense. The condition does not exist and does not deserve any consideration for statistical severity of illness, risk of mortality, or reimbursement.

 

All patients with chronic obstructive pulmonary disease (COPD), with bronchiectasis, with cystic fibrosis, and with morbid obesity have difficulty clearing carbon dioxide and have pulmonary insufficiency—and they're at home, often doing quite well, thank you.

 

So where did all of this come from? In 1993, Gordon Bernard, MD, of Vanderbilt met with pulmonologists worldwide and discussed a condition called ARDS, at that time defined as "adult respiratory distress syndrome," differentiating it from RDS, known by neonatologists as "respiratory distress syndrome." Pediatricians spoke up at this meeting and objected to the term "adult" being part of the title; they recommended changing it to "acute respiratory distress syndrome." The group agreed that this would be a beneficial change and voted to accept it.

 

A few years later, the 518.8x series was expanded, and acute respiratory distress syndrome was included in the definition of 518.82. Alternative definitions included shock lung and Da Nang lung, conditions seen in trauma and in battle and further expansion took place in 2011.

 

All patients with ARDS have acute respiratory failure, but they also have a specific acute lung injury that is definable and measurable. It has numbers and appears on chest x-rays and is a meaningful condition with mortality statistics ranging from 30% to 70%. It's sick. It's dangerous.

 

Pulmonary insufficiency is a joke as a diagnostic entity. It's embarrassing that the people defending wasteful spending in healthcare, the people responsible for the accuracy and definition of diagnosis codes, even consider an indefinable entity as a disease and something worthy of payment—something anyone, even those not sick enough to be seen by a doctor, can have. It's plain stupid.

 

Now it gets worse. Well, let's start by saying that maybe they learned something—maybe. Post-traumatic pulmonary insufficiency leads to ICD-10 code J98.4 (other disorders of lung). It shows that the term "pulmonary insufficiency" means nothing.

 

And in ICD-10, there is no equivalent of 518.82—sort of. We had a code 518.81 for acute respiratory failure in ICD-9-CM, and we have an equivalent code in ICD-10. In fact, we have two codes—J96.01 for acute hypoxic or hypoxemic respiratory failure and J96.02 for acute hypercapnic respiratory failure. In ICD-9-CM, we had 518.83 for chronic respiratory failure, and we have two corresponding codes in ICD-10, J96.11 for hypoxic and J96.12 for hypercapnic chronic respiratory failure. Cool—makes sense.

 

In ICD-9-CM, we had 518.84 for acute on chronic respiratory failure, and in ICD-10, we have the corresponding two codes J96.21 and J96.22. But 518.82 is wiped out in ICD-10—sort of. We do have J80 in ICD-10—and it's defined as ARDS, acute respiratory distress syndrome in adults and children. Yay!

 

However, if you go through the tabular list and take it word by word, "acute respiratory distress" alone takes you to J80. And that's stupid. Nothing is better. Every child with asthma will be identified as having ARDS. Every adult with exacerbations of COPD will have ARDS. And that's unconscionable and plain stupid.

 

But wait! That's not all. Check this idiocy out:

Everybody has acute pulmonary insufficiency following thoracic surgery, and many patients have acute pulmonary insufficiency following general anesthesia for almost any surgery. All obese patients or significant COPD patients have acute pulmonary insufficiency after every surgery. That's the name of the game. That's what reversal from anesthesia is for. That's what early ambulation is for. That's what incentive spirometry is for. And then people get up and go home. This will increase payments 50% for nothing.

 

And then there is J95.3 (chronic pulmonary insufficiency following surgery). Are you kidding? And that's an MCC. Oh, come on! There is no such thing.

 

CDI people will be telling intensivists and pulmonologists and anesthesiologists to document postoperative respiratory insufficiency on everyone. Our statistical meaningfulness will be in the toilet, and Medicare will go broke. We have already lost billions on use of "acute respiratory distress," and that won't go away. And it's all CMS' fault.

 

No matter how many times I've told them what they're doing and how to correct it, they won't listen. That's pure incompetence. But you can't sue them for fraud. Maybe for waste. But the Office of Inspector General was told about it—and it gave CMS a pass. Maybe they should be sued for "stupid." What's the ICD-10 code for that? 

 

Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at 770-216-9691 or rgold@DCBAInc.com. If you have a specific procedure or condition you would like Dr. Gold to address in his column, contact Editor Steven Andrews at sandrews@hcpro.com. This article was originally published in the October issue of Briefings on Coding Compliance Strategies.