Crozet Annals of Medicine: Brave New World

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Ah summer! Here at last. I am looking forward to going on vacation as soon as the new interns arrive later this month. Dr. Sudhir has gamely offered to fill in for me in the ER and in the Crozet Annals.

When and if I return from vacation the whole medical world will have changed. For the entirety of my career I have struggled to master the 14,000 diagnosis codes that the World Health Organization published in 1979 as the ICD-9, the International Classification of Diseases; Version 9. Within this bible are contained all of the injuries and illnesses that can befall a human being. The ICD diagnosis codes are universally used to generate the appropriate bill for doctor-patient encounters and to track disease and injury patterns.

While I am away my colleagues will be in training to learn the intricacies of the government-mandated switch to the ICD-10 diagnosis codes, set to occur on October 1, 2015. This is going to be a big change for us. The ICD-10 contains a staggering 69,000 codes for illnesses and injuries! I guess I will have to catch up to 55,000 new diagnoses. Piece of cake.

The ICD codes were originally formulated in 1893 and periodically updated as medical practice has changed and knowledge of diseases has blossomed. I think this is good in general; some of the current ICD-9 codes are a little out of date. In my practice, for example, code E978-“Decapitation by guillotine” is seldom used. I hope I never have to bill an insurance company for this diagnosis, but it is nice to know that I could. Similarly 020.9-“Black death” probably has been used as little as E832-“Falling off a gang plank (into water).” Arr! I can’t remember the last time I saw somebody “Injured by a cotton gin” (E919.8) or treated a patient for an “Accident involving animal being ridden injuring occupant of streetcar”- (E828.4) but maybe that still happens in San Francisco.

Perhaps the most ancient ICD-9 code of all is V65.0-“No room at the inn.” Really, that is a billable diagnosis. I assume it has to do with patients boarding in the ER, but maybe Mary and Joseph can submit a bill if they can find suitable documentation from the innkeeper in Bethlehem.

Not all of ICD-9 is out of date, however, and some of it is quite futuristic. E843 covers Fall in, on, or from aircraft injuring occupant of spacecraft. Hmm, I’m trying hard to think of the extraordinary chain of events that would lead to such an occurrence and how much could I bill for it. On the other hand, E996-“Injury due to war operations by nuclear weapons” begs the question; who would be left to send the bill to?

By and large, though, I have been happy with ICD-9, which allows me to encode the many common events I encounter at work in the ER.  787.03-“Vomiting alone” is something I see on a daily basis, and while it sounds vaguely sad, is 787.01-“Vomiting in a crowd” or 787.02-“Vomiting with company” any better? Maybe a little. It is certainly better than 569.87-“Vomiting of fecal matter” which brings up some questions, but which I have seen from time to time.

Patients can of course have several diagnoses assigned at the same visit. V60.0 -“Hobo” often has a secondary diagnosis of E013.8-“Very low level of personal hygiene.” I see this too from time to time. My coders warn me, though, that E013.8 should never be a primary diagnosis. Nor should 701.8- “Wrinkling of skin”, 318.2-“Idiot”, or 301.6 –“Inadequate personality” be primary diagnoses, although they do exist.

Some diagnoses rarely coexist however. I don’t think I have ever seen a patient with 300.29-“Fear of women” who was also complaining of V61.10-“Seven year itch.” Yes, that, too, is a medical diagnosis apparently, and yes, it does refer to the Marilyn Monroe movie of the same name about marital infidelity.

Well, before I go I thought I would preemptively study up on the impending new diagnoses of ICD-10 that I will be tasked with on my return. The government website at CMS assures me that this will be easy because “Most physician practices use a relatively small number of Diagnosis Codes that are generally related to a specific type of specialty.” Ha! We use the whole book in the ER. But at least one section practically defines our practice, the R46 codes.

R46.1  Bizarre personal appearance

R46.2  Strange and inexplicable behavior

R46.3  Overactivity

R46.4  Slowness and poor responsiveness

R46.5  Suspiciousness and marked evasiveness

R46.6  Undue concern and preoccupation with stressful events

R46.7  Verbosity and circumstantial detail obscuring reason for contact

R46.8  Other symptoms and signs involving appearance and behavior

Actually looking at this list reminds me as much of my colleagues and staff as my patients. But it is understandable when you see the list of maladies we are likely to encounter under ICD-10. Imagine my horror to discover this diagnosis V91.07XA–“Burn due to water-skis on fire” just before leaving for a vacation of waterskiing! I didn’t know water skis were so flammable. Fortunately I have time to buy a fire extinguisher and some flame retardant paint. But how does one protect oneself while traveling from V97.33XD-“Sucked into jet engine, subsequent encounter”? And how is it a subsequent encounter? How many of these can you survive? Assuming I make it off the jetway and to my destination of Florida, I still have to worry about W58.03A-“Crushed by a falling alligator”.  Sounds painful. I will keep my eyes on the sky.

The ICD-10 reminds me that the world is both a dangerous and a bizarre place. Consider the dangers:

Bitten by an Orca Whale, W56.21X. Not going to Sea World!

Walked into lamp post, W22.02XA. It happens.

Asphyxiation due to being trapped in a discarded refrigerator at the dump, T71.231D. Oddly specific, and tragic.

Insect bite (nonvenomous) of anus, initial encounter, S30867A. Why we wear clothes to picnics.

Spacecraft collision injuring occupant, V95.43XS

Spacecraft explosion injuring occupant, subsequent encounter V95.45XD.  I guess you can survive this.

Struck by a falling turkey, W61.42A. The frozen ones can really wallop you.

Drowned in a bucket of water  W16.221 –How exactly?

And the bizarre:

Lips stuck to a tuba, Y93.J4.

Injured in an opera house, Y92.253. Probably where Y93.J4 happens.

Injured in an art gallery, Y92.250. I don’t see this too often.

Injured in the driveway of a mobile home, Y92.024. I see this a lot.

Injured in a chicken coop, Y92.72.

Pecked by chicken, initial encounter, W6133XA. See Y92.72

Struck by duck, W61.62. It’s just fun to say.

And while I like to think I have seen it all, I have yet to put this in a chart. Injured in swimming pool of prison, Y92.146. I didn’t even know prisons had swimming pools.

Enjoy your summer, but watch out for falling alligators!

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