Expanded medical coding rules to be implemented for diagnoses, treatment, and procedures: What does it mean for patients?

October 26, 2012

Healthcare“Medical coding” sounds like a “back-office” aspect of health care that is not really of everyday interest to most attorneys, but the reality is very different.  Efforts are being made to computerize the practice of medicine, and all patients will be directly affected. 

New regulations have recently been released to move forward this vision of “categorized care” that is more rigid and formalized.  Attorneys will be drawn into coding issues whenever clients disagree with the care they are receiving, or have been denied care, or have complaints about the quality of care they have received.

Many of these changes have their roots in the “Health Insurance Portability and Accountability Act of 1996 (HIPAA).”

The Affordable Care Act of 2010 expanded the use of standardized coding.

These coding requirements are described as means for the “administrative simplification” of health care services.

But there is nothing simple about these changes or how they will affect health care.

There is quite an “alphabet soup” of coding abbreviations in use.

An effort is being made to categorize all diseases and treatments into computer-friendly codes, for management of services and payment.

After several delays, implementation of the new ICD-10 (tenth version of the International Classification of Diseases) code was recently set for mandatory use for inpatient hospital care on October 1, 2014.

Compliance is required by all health organizations covered by HIPAA (which includes essentially all “entities” in health care).

The “Current Procedural Terminology (CPT)” codes will still be used for outpatient care.

The “Health Plan Identification (HPID)” codes are being implemented during 2012-2016, and will describe all providers of services in detail.

And the grouping of diagnoses into “product lines” for reimbursement purposes using “Diagnosis-Related Group (DRG)” codes continues to expand in use.

Thus, diagnoses, treatments, and providers are being ever-more-tightly described and computerized.

What does this mean for patients and providers?

One of the most important results of coding is to force diagnoses and treatments into categories.

However, real-world illnesses and customized treatments may not easily fit into these detailed codes.

Flexibility is being lost in adapting to individual needs and preferences.

Efforts are being made to computerize the practice of medicine, with detailed profiles to result for patients, providers, and payers.

Conflict may result for any practice patterns that do not meet the norm.

Whenever attorneys represent clients who disagree with the care that they are receiving, the statistical linkages that go with these codes may have to be challenged.

Providers may hesitate to treat patients in “nonstandard ways” outside of established norms.

Attorneys Ferd and Cheryl Mitchell have written a recent book on implementation of the Affordable Care Act, listed as “Legal Practice Implications of the New U.S. National Health Care Plan” (July, 2012) on www.store.westlaw.com.