ARE YOU BROKEN? PROBABLY. DON’T WORRY, THERE’S A CODE FOR THAT!

Well, let’s take another look under the hood of healthcare.

Healthcare, the practice thereof, confuses many people. That’s understandable. I wish that I had more time to explain to my patients what I was doing, because it’s incredible stuff. Another thing that confuses many people is health insurance. In fact, it makes them quite angry. Understandably. But that leads to my next topic. Let’s confuse things even more with the riddle of modern healthcare that is billing and coding.

In a moment, we’ll take a look at the ICD. But first, some context. Just about everything that happens in healthcare has a number attached to it. It’s really more simple than it sounds, but here we go: HCPCS (Healthcare Common Procedural Coding System) was established by the Centers for Medicare and Medicaid Services in 1978. Though it is in the purview of the CMS, it applies to all healthcare coding. There are three levels to it, but the first level is the most common, and it contains what are called CPT codes, or Current Procedure Terminology codes. These are the codes for what the physician does to you: evaluation, surgery, lab work, prescriptions, tells you to lay of the bacon cheeseburgers, etc. Pretty straight forward.

Then there are the ICD codes, or International Classification of Diseases. These are the codes for what exactly is wrong with you, and why you came to see the Doctor in the first place. A broken arm has a code. A flu has a code. A dog bite has a code.

Ostensibly, the ICD codes were implemented to track diseases across a population. Since illness has no respect for political boundaries, these codes are also used to communicate to physicians across the planet. Researchers and physicians who may not speak English can at least decipher the ICD code.

This concept has been around for a long time. Some medical historians place the origin of the ICD codes as far back as 1763, when a French physician named Fran├žois Bossier de Sauvages de Lacroix developed a classification of 2400 diseases. (https://pubmed.ncbi.nlm.nih.gov/20978452/) The list continued to grow and develop, and by 1898, the United States was using the International List of Causes of Death. (https://pubmed.ncbi.nlm.nih.gov/9082128/). More twists and turns of the list followed, until the establishment of the United Nations and its subsequent organizations.

In 1948, the World Health Organization took over the ICD listing. The various lists used across the world were compiled, and the first official list, number 6, was published in 1949.

Again, these codes are used to track illnesses across populations and for better communication between the healthcare infrastructure of nations. However, these codes have taken on another role. These are the codes that are sent to insurance companies when a facility needs authorization for treatment, along with the CPT code mentioned above. The insurance company will plunk these codes into their computer, mull in over, and respond with how much they will cover, which 11 times out of 10 is slightly south of zero.

In my training, I was taught to look up ICD codes the old fashioned way. Our instructor handed us each a large book, the latest ICD code book, with more pages than War and Peace in large print, and we were to track down a patient’s ailment. These days, the code is simply generated when I enter it into the computer. If I enter ‘back pain,’ the code is automatically generated, with the option for further detail, should the physician think it warranted. My instructor loved to make us work for it.

Bear in mind, the ICD code book is not to be confused with the Diagnostic and Statistical Manual of Mental Disorders. That’s a whole different list of problems. I’ve got about half of them. Work is underway to integrate the DSM with the ICD, but that will probably take some time.

In 1979, the ICD-9 was published. The codes are alphanumeric, five -seven digits long, and have the option for modifiers. There were over 13,000 different codes.

In 2015, the United States adopted the ICD-10. It was greatly expanded: there are over 70,000 different codes.

The theory was, the massive increase in entries allowed for greater specificity of the ailment, and did away with the need for modifiers. You ask me, someone had a little too much time on their hands, and probably started the day a great big bowl of amphetamine flakes. Nom nom!

Yeah, the ICD-10 may have taken it a little too far. The following are actual entries from the massive list:

W61.33: Pecked by a chicken

W5921: Bitten by turtle

R46.1: Bizarre personal appearance (Oh, I got that one, for sure…)

Z63.1: Problems in relationship with in-laws (What? When does that ever happen?)

V97.33: Sucked into jet engine

R15.2: Fecal urgency

Y92.253: Injured at Opera House (Hey, it happens…. Over 6 people a year succumb to this tragedy)

Y92.241: Hurt at the library

Y92.146: Swimming-pool of prison as the place of occurrence of the external cause of injury

Y93.D1: Stabbed while crocheting

V9107XA : Burn due to water-skis on fire, subsequent encounter (I really don’t know what to say…)

V9542XA: Spacecraft collision injuring occupant (Eyes front, Major Tom!)

And my personal favorite: Y.34: Unspecified event, undetermined intent (Well, sure! That works!)

I’m making none of these up. The ICD-11 is set to published in 2022. It is said to be almost five times as large as the ICD-10.

To end on a serious note: occasionally, the ICD will need to be quickly amended. In April of 2020, a new code was added. U07.1: Covid-19.

Wash your hands! Social distance! Wear a mask! Get vaccinated! Avoid Florida! We’re not through this yet!

Fight or Flight in America as a Sociological Phenomenon

Crisis Fatigue

The link above is an interesting article. The physiological phenomenon known as ‘fight or flight’ exists in most living creatures, and is deeply ingrained into every human being. It’s a crucial component of the survival instinct, and has been for hundreds of thousands of years, existing as well as in our progenitor ancestors.

As simply as I can put it: Your 5 senses and your intuition will perceive a threat. This gets crunched in your consciousness, a poorly understood concept. This threat then gets sent to your amygdala, a part of your brain, for verification. This triggers a response in another part of your brain, the hypothalamus. The hypothalamus wears many hats (and we really don’t know how), but it kind of serves as a command center for a lot of things. In this sense, it triggers the fight or flight mechanism. Admiral Hypothalamus will activate your sympathetic nervous system, a part of your electrical wiring, which fires up your adrenal glands, which generally have about 8 cups of coffee in them already. Your adrenal glands will freak out and push the panic button, and secrete a number of hormones, mainly adrenaline, cortisol and norepinephrine. The adrenaline will ramp up your blood pressure and your pulse, and accelerate the actions of your lungs and muscles. The cortisol will adjust your glucose (stuff you get from food) to provide a burst of energy. The norepinephrine will flood your brain, increasing alertness and response times. Every other system takes a back seat, including rational thought. At this point, you’re ready to kick some ass. This goes back to the time when our ancestors had to face off grizzly bears. We don’t have to do that anymore (except for those idiots in Yellowstone who want a better picture), but fight or flight is very much with us today, in response to both physical (a mugger, a mean dog, road rage) or emotional (fight with your spouse, boss wants to see you, the principal called) experiences. Eventually, the response will abate, and you are left exhausted and weak.

Problems happen when people are under constant fight or flight, and the response does not get a chance to wear off. This will result in anxiety, depression, PTSD, heart problems, or all of the above.

I know nothing of sociology. However, this article posits the idea that American society has been living under a steady, constant fight or flight response ever since 2020 started. We are now suffering from the effects of 3 social phenomenons that are causing Americans a huge amount of stress. It started with the emergence of a virus we thought we may be able to control, but we were very wrong. Then, racism reared its ugly head once again, when George Floyd (and, let’s face it, he’s not the only one) was murdered by a police officer. This has triggered a massive social disruption of anger and violence. Perhaps worst of all, the federal leadership (dammit, GOP, I hate to say I told you so… I take no glee in his failures) has been fully exposed as incompetent, dysfunctional, and unwilling or unable to rise to these challenges. In fact, our President’s behavior has gotten worse, and it is clear that he is in way over his head. In the meantime, the violence continues, and the pandemic has now killed 111k Americans. At this point, things do not show any signs of significant improvement or healing. As with an individual, problems will arise when the fight or flight response does not get a chance to settle down. We are seeing that now, in the hatred, anger, depression, isolation, anxiety and general “I’m pissed off today” attitude in nearly every American. If things do not settle down, the damage to society, as with an individual, will be massive, and will take longer to heal than we can imagine.

Well, I’m just babbling instead of doing my homework. Sorry for the long post. I better hit the books. Wash your hands!