Middlebury, Vt.

Life in the middle of Vermont.

Thursday, September 22, 2011

Human Folly? There’s an ICD-10 Code for That

A key premise of Vermont's admirable attempt to institute single-payer healthcare is that it will rationalize an often irrational system. With smart people like Gov. Peter Shumlin and local House Rep. Mike Fisher leading the charge, maybe it will.

But healthcare is a world where it’s illegal to acquire a legal drug, and where there will soon be hundreds of insurance codes for how people get hurt by animals.

One look at recent headlines is enough to suggest that federal bureaucracy and legal ambiguities – not to mention the pure irrationality of human behavior -- will continue to complicate a healthcare system that makes Alice’s Wonderland seem simple.

To start with, the federal courts can’t decide whether Pres. Obama's healthcare reform act -- the law upon which rests our state's single-payer efforts -- is even constitutional. Courts in different jurisdictions have issued sharply differing decisions.

Clearly, it's going to be up to the highly partisan (read: Republican) US Supreme Court to decide once and for all if healthcare reform can be fully implemented.

Even here in Vermont, we have our share of legal ambiguities. Take, for example, the case of Glenn Myer.

Myer, a 52-year-old former pharmacist, has a little company called Green Herbalist. A recent report in Seven Days outlines Meyer's effort to add to Vermont's agricultural diversity.

Except Myer isn't growing heirloom tomatoes or a new kind of string bean. He's growing marijuana.

At two facilities in Lamoille and Caledonia counties, he cultivates marijuana for Vermonters who have a doctor's permission to partake of the weed because of their medical conditions.

I’ve said before in this space that I think marijuana should be legal for adults, so long as it’s regulated similarly to alcohol. For now, though, Myer's entrepreneurial herbalism occupies a gray area of the law, one that intermingles a largely illegal drug with legitimate healthcare concerns.

His business is another example of a long-standing contradiction in state law. While it's legal to use marijuana in Vermont if you have a doctor's permission, until recently the law established no clear way for Vermont patients to legally acquire the marijuana they are allowed to use.

A new law authorizes the existence of up to four not for-profit medical marijuana dispensaries in the state. But they won’t begin operating until the middle of next year.

In the meantime, the legal marijuana users who are Myers’ customers will have to hope his operation doesn’t get railroaded out of existence by police and prosecutors.

Even if Vermont manages to straighten out the confusion in its own healthcare system, Uncle Sam seems determined to make the whole thing way more complicated.

Nothing demonstrates that better than the pending implementation of new billing codes for medical services.

Under the rubric of ICD-10, the new system will in two years replace 18,000 billing codes with 140,000 of them.

The idea is to make billing much more precise. That way, payers such as Medicare and Cigna will have a better idea what they're paying for, and health authorities can much more accurately track the specifics of injuries and disease.

On the face of it, it seems like a good idea.

But somewhere along the line, things got out of hand.

For example, there are nine different codes for an injury incurred by a macaw. There are separate codes for injuries related to the ducks, geese, turkeys, and chickens -- 312 animal codes in all.

The international system of the World Health Organization manages to get by with only nine codes for animal-related injuries. But they don't have ICD-10's penchant for detail -- which has also led to separate codes distinguishing between whether or not a patient was bitten by a turtle or struck by a turtle.

One aspect of the new system seems specifically reserved for alcoholics: There's an indication for "walked into lamppost, initial encounter" -- and a separate one for "walked into lamppost, subsequent encounter."

Other parts of the system just seem arbitrary.

When ICD-10 is implemented, for example, clinicians and billing codes will be able to indicate whether the patient evidence has a "bizarre personal appearance" or simply a "very low level of personal hygiene."

My personal favorite in the new system is the code for "burn due to water skis on fire."

I am not making that up.

Rhonda Buchholtz, an expert coder who trains others, told the Wall Street Journal she wondered where that code would be used. How did it happen that the skis caught on fire and burned the patient?

"Is it work-related?" she wants to know. "Is it a trick skier jumping through hoops of fire?"

No word yet on whether there will be a code for Vermont herbalists who are classified as "too stoned to grow."

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