It sure isn’t ecstasy.  Yesterday, March 31, 2014 our US Senate passed a bill to delay the ICD-10 implementation  for another year.  It was supposed to go into effect on October 1, 2014.

For most people, ICD-10 is an unfamiliar term, but for many of us in the medical field this is a dark cloud that has been looming over us for years.   This is the new and improved coding system (60 thousand medical diagnosis codes so that WHO amongst others can have its stats on what’s happening).

I’ve been working on this for several months now, and it seems that many are seeing what is on the horizon.  October surpriseh/t Adrienne

Codes exist for being hurt at the opera (Y92253), walking into a lamppost (Y92253), walking into a second lamppost (W2202XD), getting sucked into a jet engine (V97.33XD), and being burned due to water skis on fire (V91.07XD).

Remember death panel overlords will be able to review these codes and know exactly what happened at what moment wherever to deny or approve what YOU may or may not believe is medically necessary.  (Forget what you or your physician are thinking.)  This is how decisions will be made.

From one of the comments.  Yes, I’ve heard these scenarios as well.

ICD-9 vs. ICD-10

In one example a CMS executive gave me, the new codes will impact patients and insurers in quite basic ways. Here’s the scenario she gave me. Under ICD-9: In April, Johnny falls off a neighbor’s tree, breaks his left arm, and goes to the hospital. Doctors fix him up and insurance pays. In May, Johnny falls off the same neighbor’s tree, breaks his right artm, goes to the hospital, doctors fix him up — but insurance balks, saying “We already paid for this.” That’s because ICD-9 doesn’t specify right or left limb. Under ICD-10, the doctor has to state s/he is working on the left or right arm. The insurance company sees it’s a different arm and paperwork goes through smoothly.
Perhaps? Of course, klutzy little Johnny who likes trespassing could ostensibly continue to break the same arm. But at least if he alternates arms it’ll be easier for his parents to get the bills paid — until they finally ground him or the neighbor gets a mean dog and/or a taller fence.

Social problems?  No worries, CPS can use those codes to take care of Johnny if his parents won’t fix him.  Just like this, and yes I am being sarcastic.

Z63.1: Problems in relationship with in-laws

According to a director of ICD-10 codes, this actually is a billable code that can be used to specify a diagnosis. Providing social context about trouble in the family could also be important for understanding the patient's source of stress or, in more serious cases, injury from domestic violence.</p><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /> <p>(Image: All in the Family cast, Wikimedia Commons)

According to a director of ICD-10 codes, this actually is a billable code that can be used to specify a diagnosis. Providing social context about trouble in the family could also be important for understanding the patient’s source of stress or, in more serious cases, injury from domestic violence.

Or that bird bite.  Yes, I now am a parent to FOUR parrots so I will have to watch out for my fingers.

W61.01XA: Bitten by parrot, initial encounter

Ah, but let’s move on…how will this impact your doc?  I’ve listened to a few webinars that have recommended solo practices request a 6 month loan to cover operating expenses since this is a major overhaul of the healthcare system.  Cost to implement this is high considering that reimbursement for physicians has gone down, down, down.  Estimates range in the $85,000+ (for a solo practitioner) to several million dollars in cash reserves for different size practices implementing ICD-10.  Via October surprise.

The current version, the ICD-9, uses a 4- or 5-digit number to code for a particular disease, such as 540.9 for appendicitis.  The ICD-10 will have up to 7 alphanumeric characters to specify a condition, such as S52.521A for “torus fracture of lower end of right radius, initial encounter for closed fracture.”  And there are now over five times as many codes for doctors and hospitals to choose from.

But isn’t specificity better?  Sure it is.  Big data is the new frontier in medical research, making sense of the huge amount of generated health care data.  But can this go too far?

In an effort to push specificity to the limit, some ICD-10 codes have gotten silly.  Codes exist for being hurt at the opera (Y92253), walking into a lamppost (Y92253), walking into a second lamppost (W2202XD),

W22.02XD: Walked into lamp post, subsequent encounter

…getting sucked into a jet engine (V97.33XD), and being burned due to water skis on fire (V91.07XD).

Let’s get to the down and dirty.

First, medical practices and hospitals must know and have all of these 68 thousand codes readily available to add to the medical record in order to bill correctly and hope to be paid.  One more distraction for physicians, aside from all of the daily distractions of electronic records.  When physicians pay more attention to their computer screen or tablet than to the patient, guess who suffers.  This is the reason why texting and driving is illegal.

(Bold emphasis is mine.)

Second, electronic medical records (EMR) must be able to incorporate these codes into the exam or procedure report.  Are all EMR vendors up to speed on these codes?  Will their system upgrades work as advertised?  Or will they work as well as the website?  And if the codes don’t work, physicians and their practices don’t get paid.  Yet landlords, employees, and utility companies still want to be paid.

Third, will the insurance companies recognize each of these new 68 thousand codes, correctly match them to billed procedures, and promptly pay the providers?  If I treat a patient with macular degeneration with a monthly dose of a $2,000 drug, I now bill a single code, which insures that I will be paid.  Under the ICD-10, there will be 20 codes, specifying which eye(s) and severity, that allow payment.  Will every insurance company have each of these codes in its computers?  Will it recognize each code?  Remember that these are the same insurance companies that don’t even know who has actually paid their insurance premiums.

The American Medical Association announced this week that ICD-10 implementation will cost three times as much as originally estimated.  The  “costs of training, vendor and software upgrades, testing and payment disruption” could be $225,000 for a small medical practice and over $8 million for a large practice.  How do medical practices of marginal profitability absorb these costs?  With physician reimbursement rates set to grow at only half a percent per year over the next five years, far below the true rate of inflation of close to 10 percent, the financial writing is on the wall. This will accelerate the demise of private practice, already underway due to ObamaCare.  Come October 1, “The doctor is in” may be a phrase of historical interest only.

Electronic medical records have already slowed many practitioners in the real world although you will hear from many in the Ivory Tower how great they are.   So, let’s hear it from someone commenting who actually lives in the real world and has to do the actual work.

ICD-10 is “granular.”  It lets researchers, insurance companies, the feds, and anyone else who gets their eyes on the data do great things.  This data is valuable.  To get this data, I, a solo practitioner, must buy software, recode the diagnosis for every patient, code it again the next visit as the specificity has changed, and so on.

And what am I paid for providing this valuable data?  Why, nothing at all!  In fact, if the computer at the other end doesn’t like my code, I don’t get paid for my work.  And the payments here in primary care land are, shall we say, inadequate for the work we do, let alone for the data processing services we are required to provide for free in order to get our pay.


Gosh, he’s polite.  Here’s another reality check comment.

Sorry folks, but I’m one of hundreds of over 65 Family Docs in private practice who are planning to close our practices 9/30/14 if ICD10 isn’t delayed. It’s going to cost tens of thousands to convert and there will be zero return on that investment. Most of us are living hand to mouth paying our help now and the advice to “have six months revenue in reserve” or “open a line of credit” isn’t realistic. It makes perfect sense to use ICD10 at the hospital level and a much more limited set at the office. If you think there is any clinical benefit in letting an insurance carrier know if a kid has a left or right ear infection or if you hit your head walking into a lamppost you have major problems.

More mocking…my favorite

T71.161D: Asphyxiation due to hanging accidental, subsequent encounter.

This example turned up in the comments on the blog post I cited about the common misunderstanding of the meaning of “subsequent” in ICD-10. As a reader pointed out, in this case the formula has clearly been carried too far: Since by definition asphyxiation is fatal, “one would not have a subsequent encounter.”

How does this affect the patient?   This is supposed to be about the patient afterall.  The incentives to switch to EHR have now become much more difficult to navigate.  Time consumption is a big deal. Bottom line:  More time is spent at the computer than taking care of people.   The cost is high and excruciating in many ways.   Training for the these “improved” protocols is expensive.  Think staff training, new equipment, blah blah blah.

I say take a deep breath every morning!  Nom sent this one over because we don’t want Mcnorman to go bonkers.  Thanks for letting me rant.  BTW, ICD-10: Painful To Implement, Painful To Delay has more great mocking pics.

Great reading:  War on doctors.

“Conscious uncoupling?”  Seriously, who gives a flip?  No one.

Guide to New Age can’t state the obvious, so this is the new and improved meme for hipsters.

Apportioned harmonic uncoupling: Separating because you hate your partner’s iTunes playlists.

Ascended visualization: Celebrities who think they’re actually good people because they have 100,000 Twitter followers.

Astral schism: Splitting up even though your horoscope says you won’t.

Bhagavad cheater: A guidebook for justifying extramarital affairs by calling it “open marriage.” (Also known as “out-of-body experiences.”)

Conscience uncoupling: Going out, getting really drunk, making an ass of yourself, then not feeling so bad about it the next day (see also Sheenism).

Deja views: That sinking feeling you get when you announce your breakup online only to have your website crash for two days.

Exoteric disembodied morphism: When you break up because your partner got too fat.

Gnostical teaching: Hiring a tutor for your daughter rather than having nightly fights over seventh grade math homework.

Harmonic channeling: The kids’ realization that hanging out at Dad’s place is more fun.

Primatial animism: What monkeys call it when they break up.

Subconscious convection: When one spouse breaks wind so often in his or her sleep that a spouse has no choice but to consciously uncouple.

Unconsciously coupling: A successful Saturday night drinking binge.

Let the mocking commence!  Gwen is a dumbell.  She thinks being a moviestar is far more difficult than raising children (she has a nanny) or working a desk job.

Well, she does behave like she is one.

…Like Hillary Clinton before her, she was an accomplished lawyer with policy smarts. But unlike Clinton, she was also an electrifying speaker, able to translate her husband’s lofty agenda into a grounded, commonsense morality. When Michelle Obama entered the White House in 2009, she attracted staffers eager to bring about the policy prescriptions that she had so forcefully advocated on the trail.

This meant that, when it came to the search for a communications director, the office had no trouble finding a candidate with impressive credentials. Kristina Schake, a California political operative, had led the fight against California’s Proposition 8 and helped steer Maria Shriver’s annual women’s conference, widely hailed as a breakout success. Schake’s hiring seemed to signal that the first lady was ready to embark on a new phase, focused on issues of public health and equality. “Reading the tea leaves, I was struck by the level of ambition it communicated,” says Jodi Kantor, the New York Times political reporter and author of a book about the Obamas.

Two and a half years later, Schake would be out the door, replaced by an executive from Estée Lauder. What Schake couldn’t have known in 2010—and what Mrs. Obama’s hyper-motivated, highly accomplished staffers would never publicly admit—is that the first lady’s office can be a confining, frustrating, even miserable place to work. Jealousy and discontentment have festered, as courtiers squabble over the allocation of responsibility and access to Mrs. Obama, both of which can be aggravatingly scarce. Fueling these sentiments, according to former East Wing insiders, is the exacting but often ambivalent leadership style of the first lady herself.


But it was never completely clear what the standard of perfection should be. “There’s no barometer: The first lady having the wrong pencil skirt on Monday is just as big of a fuck-up as someone speaking on the record when they didn’t mean to or a policy initiative that completely failed,” says another former aide. “It just made you super anxious.” Another past employee described a common feeling of “how can we be the caliber that we’re expected to be with no attention and no resources and being an afterthought? And all that can make for sparks. Friction.”

(Looks like POTUS got the snips at some point.)  So, who actually runs this country?

Most important, both were comfortable taking orders from Valerie Jarrett, the first lady’s self-appointed enforcer and avatar. Let’s Move! saw its first two directors wash out—one a veteran political organizer and the next a pediatrician—to be replaced in 2013 by Sam Kass, the Obamas’ longtime chef and garden-master.

Shouldn’t they begin banning “bossy” in the White House first?  And start with ValJar and Meechelle.  I also hear that on this China trip, the staff at the hotel can’t stand Meechelle’s mother because she barks orders all the time.  So that’s where she gets that “bossy” thing.

Sharyl Attkison said buh bye to CBS.  She has a book and now she has a website.

Links of interest

Is Press going too far in cooperating with government censorship requests?

CBS Exclusive: Alleged scheme targets free military tuition assistance at taxpayer expense

CBS: Massive Farm Bill contains new Christmas tree fee and a billion dollars a page in spending.

CBS Exclusive: IG still investigating alleged missing gun from Brian Terry Fast and Furious murder. Jan. 21, 2014

Why the press shouldn’t dismiss vaccine safety skeptics

Oops! Article says government mistakenly sends reporter memo on how to deny Freedom of Information requests

First post-Benghazi assignment for new military team

CNN, Fox and al-Jazeera America among top searched news sources on Google

Iraq city falls fully into al-Qaeda group’s hands

NSA won’t say whether it spies on Congress


Russia’s deputy prime minister laughed off President Obama’s sanction against him today  asking “Comrade @BarackObama” if “some prankster” came up with the list.

They must have seen this pic of teh won.

Most of us know that he lives in an alternate universe.

Dr. Suzanne Levine DPM
885 Park Ave Suite 103-105
New York, NY 10021-0325

Yes, she is a provider for Medicare and she does take insurance.  I want to know what the Hell she was billing for in order to garnish this much money while the rest of us are receiving pesos for payment?  How does one double bill and get away with this?

A Park Avenue podiatrist billed $178,900 to fix two crooked toes, office procedures that lasted less than an hour.

Amazingly, insurance giant United Healthcare/Oxford paid most of the bill, cutting a check earlier this month for $175,098.80.

Instead of sending the check to Suzanne Levine, a foot fixer with a roster of celebrity clients, United Healthcare mailed it to the shocked patient. And Levine’s office has been frantically trying to collect the money.

“The doctor’s office calls me up and says you’re getting a check, we want the check. It’s our check,” said Keith Kantrowitz, a Manhattan mortgage banker whose wife was treated by Levine. “I said, wait a minute, I don’t owe you . . . money.”

The outrageous charges, and payment of them, has health-care experts scratching their heads.

“I’m stunned,” said Dr. John Santa, a director of Consumer Reports Health. “Did they use a proton beam for this?”

There are no laws regulating prices, state officials say. Other Upper East Side podiatrists say they don’t bill more than $3,000 to correct a hammertoe.

That is true, you can bill a million dollars but the insurance companies have contracted rates for every procedure.   This just cannot be correct.

The shocking check for $175,098.80.

Kantrowitz’s wife, Renee, sought help from Levine last year after seeing her on television. Upon feeling a tingling sensation in her foot, she made an appointment with the publicity-conscious Levine, who calls her office Institute Beauté. (She has glossy photos and letters of gratitude in her office from the likes of Anna Wintour, Barbara Walters, Bill Cosby, Oprah Winfrey, Katie Couric, Liam Neeson and Naomi Campbell.)

Levine — who as a podiatrist is not a medical doctor — injects Botox to smooth out tootsies (“for that ‘angry’ look”) and touts procedures such as “foot face-lifts.” She also injects Juvéderm and other chemicals into the pads of feet as a cushion against the pain of high heels.

Levine offered to straighten out one of Kantrowitz’s toes, making a small incision in her foot, a procedure done in one of her exam rooms that took about 25 minutes. When Kantrowitz returned for a follow-up, Levine did another toe in a similarly short session.

The doctor assured Kantrowitz that everything would be covered by her insurance.

But Levine then billed Kantrowitz’s credit card $6,000 and tried to squeeze more cash out of the insurance carrier. A lot more.

The insurer agreed to pay $170,940.04 plus $4,158.76 in interest, according to the explanation of benefits that Renee Kantrowitz received along with the check.

Please, someone needs to do some major investigating here.  Physicians are punished all the time with pennies being paid on the dollar for life saving procedures.  A hammer toe for beauty?   This is outrageous.

Just say it is so and you’re off the hook for now.  The Emperor speaketh.

That seven-page technical bulletin includes a paragraph and footnote that casually mention that a rule in a separate December 2013 bulletin would be extended for two more years, until 2016. Lo and behold, it turns out this second rule, which was supposed to last for only a year, allows Americans whose coverage was cancelled to opt out of the mandate altogether.

This lax standard—no formula or hard test beyond a person’s belief—at least ostensibly requires proof such as an insurer termination notice. But people can also qualify for hardships for the unspecified nonreason that “you experienced another hardship in obtaining health insurance,” which only requires “documentation if possible.” And yet another waiver is available to those who say they are merely unable to afford coverage, regardless of their prior insurance. In a word, these shifting legal benchmarks offer an exemption to everyone who conceivably wants one.

Minor detail, right?  Where are the sinkholes when you need them?


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