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Diagnosis Detail

September 18, 2011

At the end of 2011, the national standard for health care EDI transactions, currently called HIPAA 4010, will “expire.” Health organizations will have to be able to use a modified EDI format, known as 5010, to transmit health care claims and other health-related EDI transactions. The HIPAA 5010 standard will make numerous improvements to the existing EDI standards, one of which is the ability to later implement a more robust set of diagnosis codes called ICD-10 codes. Currently, health diagnosis are recorded in a standard known as ICD-9. Organizations will no doubt spend hundreds of millions of dollars to implement the ICD-10 change, not counting 5010 transition costs.

Why change standards? This is the question asked  by the Wall Street Journal article “Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way.” In this article Anna Wilde Mathews explores some of the more humorous aspects of the new code set, which increases the number of usable diagnosis codes from about 18,000 to well over 100,000. More interesting is the explosion of detail involved in some specific code subgroups. For example, “With the move to ICD-10, the one code for suturing an artery will become 195 codes, designating every single artery, among other variables, according to OptumInsight, a unit of UnitedHealth Group Inc. A single code for a badly healed fracture could now translate to 2,595 different codes, the firm calculates. Each signals information including what bone was broken, as well as which side of the body it was on.” (italics are mine, here and elsewhere, and denote excerpts from the article.)

Why did health officials construct this byzantine rats-nest of encoding? Mathews explains: “Medicare and CDC officials say codes were selected based on years of input from medical experts in various fields. Codes describing the circumstances of injuries are important for public-health researchers to track how people get hurt and try to prevent injuries, they say.”

Well, I can accept that motivation. The fact is, implementation ICD-10 across the nation is going to be very expensive. I would like to believe that, as a matter of policy, the implementation of ICD-10 will offer enough benefit to justify its cost. But perhaps that money could better be spent on improving health care delivery or reducing health care costs. Time will tell whether the benefits outweigh the costs. In the meantime, you can read the article and start to form your own impressions. The Wall Street Journal can be found online at

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