Updated on: November 21, 2016

CMS Setting Itself Up for Billions in ICD-10 Waste

Original story posted on: September 14, 2015

Sometimes people do their homework with setting up a new system, and sometimes they don’t. Sometimes, even when those people do their homework, it may not be adequate, and billions of dollars of avoidable wasteful spending occurs.   

But too often “they” won’t listen. 


This has happened for decades with ICD-9, and through persistence of outside influences, some corrections got made, and some more are in the planning phase to be instituted in ICD-10. One particular concept started in ICD-9 and will be expanded in ICD-10 – and it will cost taxpayers and the Medicare program billions of dollars – but again, “they” won’t listen.

The concept is pulmonary insufficiency. In ICD-9, we had three codes for this – 518.82, other pulmonary insufficiency, not elsewhere classified; 518.52, other pulmonary insufficiency, not elsewhere classified, following trauma and surgery; and 786.09, respiratory insufficiency. 518.82 is a comorbid condition in the CC category.  518.52 is a major comorbid condition in the MCC category. 786.09 is a symptom of who-knows-what condition that a patient may have that needs workup and finer definition.

The fact is that pulmonary insufficiency has no definition other than the implication that the lungs aren’t doing all that they should – strictly speaking, it means not clearing carbon dioxide from the blood adequately. It is unmeasurable and indefinable. It is open to wide interpretation and means absolutely nothing as a diagnosis.

Yet both 518.82 and 518.52 fall in the same category as acute respiratory failure, whether due to disease or due to trauma and surgery – and these are both measurable and definable as recognized conditions by anyone who treats patients, old and young. The numbers are there, and you’d better meet the criteria in order to avoid being accused of unethical coding and billing. But “insufficiency” is a vague term that in some contexts has no meaning to anyone, and it is worthless in the practice of medicine other than for the purposes of telling someone to look for a disease.

Giving “acute respiratory failure” some statistical pertinence and appropriate reimbursement for treating it makes sense, both for the physician who is actually evaluating and treating the patient and the facility in which that treatment is being rendered. Giving “other pulmonary insufficiency” similar consideration is a joke. The Centers for Medicare & Medicaid Services (CMS) has been told this over and over for the past 10 years and it won’t do anything about it. The National Center for Health Statistics (NCHS) has been told about this for the past 10 years and it won’t do anything about it. Why? Maybe because they made the mistake in 1993, when the code set was introduced, and they’d be embarrassed to admit their error now. Nothing else makes sense. The condition does not exist and does not deserve any consideration for statistical severity of illness, risk of mortality, or reimbursement. All patients with COPD, bronchiectasis, cystic fibrosis, and/or morbid obesity have difficulty clearing carbon dioxide and have pulmonary insufficiency – and many of them are at home, often doing quite well, thank you.

So, where did all of this come from? In 1993, Gordon Bernard, MD of Vanderbilt University met with pulmonologists worldwide and discussed a condition called ARDS, at that time defined as “adult respiratory distress Syndrome” (differentiating it from RDS, known by neonatologists as “respiratory distress syndrome.”

Pediatricians spoke up at this meeting and objected to the term “adult” being part of the title and recommended changing it to “acute respiratory distress syndrome.” The group agreed that this would be a beneficial change and voted to accept it. That year, the 518.8x series was introduced and “acute respiratory distress syndrome” was included in the definition of 518.82. Alternative definitions included shock lung and Danang lung, conditions seen in trauma and in battle. All patients with ARDS have acute respiratory failure, but it’s a specific acute lung injury that is definable and measurable. It has numbers, it has appearance on chest X-ray, and it is a meaningful condition, with mortality statistics ranging from 30-70 percent. It’s dangerous.

Pulmonary insufficiency simply doesn’t work as a diagnostic entity. It’s embarrassing that the people defending against wasteful spending in healthcare, the people responsible for accuracy of ICD codes and definition of ICD codes even consider an indefinable entity as a disease and worthy of payment – even for patients who are probably not even sick enough to be seen by a doctor. It’s plain stupid.

It gets worse.

Let’s start by noting that maybe, just maybe, they learned something. “Post-traumatic pulmonary insufficiency leads to ICD-10 code J98.4, other disorders of lung. This shows that the term “pulmonary insufficiency” means nothing. And in ICD-10, there is no equivalent of 518.82 – well, sort of. We had a code, 518.81 for acute respiratory failure, in ICD-9 and we have an equivalent code in ICD-10. In fact, we have two codes – J96.01 for acute hypoxic or hypoxemic respiratory failure and J96.02 for acute hypercapnic respiratory failure. In ICD-9, we also had a code, 518.83, for chronic respiratory failure, and we have two corresponding codes in ICD-10, J96.11 for hypoxic and J96.12 for hypercapnic chronic respiratory failure. This makes sense. In ICD-9, we also had 518.84 for acute on chronic respiratory failure, and in ICD-10, we have the corresponding two codes, J96.21 and J96.22. But 518.82 is wiped out in ICD-10. We do have J80 in ICD-10 – and it’s defined as ARDS, or acute respiratory distress syndrome in adults and children. However, if you go through the tabular and take it word by word, “acute respiratory distress” alone takes you to J80. And that’s stupid. Nothing is better in this scenario. Every child with asthma will be identified as having ARDS. Every adult with exacerbations of COPD will have ARDS. And that’s unconscionable.

But wait! That’s not all:

J95.1Acute pulmonary insufficiency following thoracic surgery

J95.2Acute pulmonary insufficiency following nonthoracic surgery

Everybody has acute pulmonary insufficiency following thoracic surgery, and many patients have acute pulmonary insufficiency following general anesthesia for almost any surgery. All obese patients or patients with significant COPD have acute pulmonary insufficiency after every surgery. That’s the name of the game. That’s for what reversal from anesthesia is intended. That’s for what early ambulation is intended.  That’s for what incentive spirometry is intended. And then the patients get up and go home. And it will increase payments by 50 percent for nothing. 

And then there is J95.3, chronic pulmonary insufficiency following surgery. And that’s an MCC. Oh, come on! There is no such thing.

Clinical documentation improvement (CDI) people will be telling intensivists and pulmonologists and anesthesiologists to document post-operative respiratory insufficiency on everyone. Then our statistical meaningfulness will be in the toilet and Medicare will go broke. We have already lost billions on use of “acute respiratory distress,” and that won’t go away. And it’s all CMS’s fault. Yet no matter how many times I’ve told them what they’re doing and how to correct it, they won’t listen. That’s pure incompetence. But you can’t sue them for fraud (maybe for waste).

But the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) was told about it, and it gave CMS a pass.


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Robert S. Gold, MD

(1942-2016) The late Robert S. Gold, MD, was a nationally known physician, responsible for having championed clinical documentation with a peer-to-peer educational approach in hospital organizations. Dr. Gold was a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper data streams, proper communication within the medical records and proper reimbursement. Dr. Gold served on the ICD10monitor editorial board from 2011 through January 2016.

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