ICD-9 codes present challenges to determine best medical providers
For selecting the best medical networks, the accuracy of ICD-9 codes in workers' comp is very poor.
The ICD was developed by the World Health Organization to classify diseases and other health problems, according to the International Association of Industrial Accident Boards and Commissions. The codes enable storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes and provide the basis for the compilation of national mortality and morbidity statistics by WHO member states.
Workers' comp participants are using the information to compare the quality of medical care. "The idea is to understand the data to determine which providers are giving employees the best outcome," said Carla Wynn, assistant vice president for strategic claims management at Aramark Corp. "The tricky thing about doing that is understanding what does the data really mean."
For example, if a worker has comorbidities, some state workers' comp systems may require treatment of those unrelated conditions under the workers' comp claim, which could skew your analysis. The ICD-9 codes for the unrelated conditions might become primary because they cost more dollars. "You spend money to do this analysis and you're doing it on diabetes, which has nothing to do with the injury," Wynn said. "If there is more than one code, which one do you pick?"
There are several schools of thought. Some experts advise using the code for the initial injury, while others suggest using the code associated with the most expensive issue in the claim.
"Say what appeared initially to be a back sprain actually was a more serious injury that created the need for spinal surgery. You don't want to compare simple back sprain claims -- or their associated physicians -- with claims where surgery was appropriate and ultimately necessary," said Maddy Bowling, principal in Maddy Bowling & Associates Consulting, a workers' comp/integrated disability consulting firm. "If you want to compare one case to another, one physician to another or identify a particular company's loss cost drivers, you must have the diagnoses in the right 'bucket' in order to adjust for severity in your comparisons."
Bowling's firm identifies all the codes associated with a claim, adds up the dollars for each, and then lets the client make the final decision. However, she believes using the code with the most dollars attached as the primary one is a valid approach for better analytics. "There is often a secondary one which must also be considered."
ICD-10. What may complicate things a bit is the impending launch of ICD-10 codes. They expand the diagnosis codes from 13,500 to 69,000 and the procedure codes from 4,000 to 72,000, to enable more specificity and better align diagnosis and procedure codes with current medical practices.
In October 2013 all HIPAA covered entities will be required to transition to ICD-10 codes. While workers' comp is not covered by HIPAA, the IAIABC believes it will clearly impact the system.
"It is unlikely that payers, providers and other reporters will maintain systems to support the use of ICD-9 after October 2013," the IAIABC said. "This will result in the need for both business and technical changes for workers' comp administrative agencies and any organization that submits medical data including insurers, third party administrators and medical providers." The IAIABC is forming a task force to address the impact on workers' comp entities.
Read more at the WorkersComp Forum homepage.
December 16, 2010
Copyright 2010© LRP Publications