By Cindy V. Culp

Tribune-Herald staff writer

If deciphering that explanation of benefits sheet you get from your health insurer after a doctor’s visit gives you a headache now, you’d better stock up on aspirin.

The federal government is overhauling the coding system that doctors and hospitals use to bill insurers. The end result will be a system that has 10 times as many codes.

Sprain an ankle? Your doctor’s office will have 45 codes to choose from with the new system, instead of the current five.

Need angioplasty? Right now, your provider has to know just one code for the artery-opening procedure. Under the new system, though, there will be 1,170 different codes to sift through.

For consumers, the huge increase in codes will likely mean the paperwork they get from insurers will be bulkier, experts say. In the short term, it also could mean more billing errors as the industry adjusts, they say.

Nearly everyone in the medical field agrees change is needed, experts say. The current coding system is 30 years old and doesn’t have room to keep up with advances in technology. Nor does it capture differences between patients who may have the same ailment but different root causes or expected rates of recovery.

Plus, the new system will encourage the adoption of a nationwide electronic medical-information system and make it easier to track outbreaks of disease, federal officials say.

Still, there is disagreement about how much change is needed and how soon. For example, some say that while one code for angioplasty is inadequate, 1,170 is overkill.

Also, some doctors and insurance companies take issue with the three-year timeline the government has chosen for the project. The new system is set to take effect in 2011. But at least five years may be needed to make the switch go smoothly, some say.

A person’s opinion about the switch largely depends on his or her job, said Dr. James Rohack, president-elect of the American Medical Association and director of the Center for Healthcare Policy at Scott & White, a local health system.

Hospitals, as well as doctors in certain specialties, stand to gain the most, Rohack said. Family medicine doctors and physicians in small practices have the most to lose.

Hospitals are excited about the new system, known as ICD-10, Rohack said, because they believe it will increase their revenue. Because they get paid more for care given to sicker patients, the more they can use coding to describe a patient’s condition, the better, he said.

Also, the new system should help hospitals get more money for advanced surgeries, Rohack said. The codes will capture details such as the type of equipment used, as well as intricacies of some procedures.

For example, a suture, or stitch, is now counted as only one action, Rohack said. Under the new system, there will be different codes based on how many layers of skin the stitch goes through, he said.

Similarly, doctors who perform surgeries or other complicated procedures are more excited about the new system than those with more general practices, Rohack said. Not only are they dealing solely with one organ or body system and thus feel the need to differentiate between similar procedures and diagnoses, but they also can hire coders who specialize in one area, such as cardiology, he said.

Doctors with more general practices, on the other hand, have to have coders who know the numbers for every body system. That is, if they hire coders at all. At many smaller practices, doctors and regular staff members do the coding themselves.

That’s the way it is at Dr. Timothy Martindale’s office in Waco. The family medicine doctor said his employees have to learn coding in addition to their primary job.

“The people (the switch will) hurt is the general, independent businessmen who don’t have time to figure this out,” Martindale said.

Because doctors like Martindale get paid only for seeing patients, he said, anything that takes time away means less money. That creates a nasty cycle in which doctors have less time to spend with individual patients because they have to care for higher volumes to make up for money lost on uncompensated activities.

Because of that reality, many doctors “undercode,” Martindale said. Instead of using codes that accurately describe and detail everything they did — which would net the highest reimbursement — they omit services or list a general code instead of a more specific one.

Because the new system will increase the number of options nearly 10 times — to 155,000 codes — undercoding is likely to occur more often, Martindale said.

On the hospital side, the changeover also will take substantial resources, said Glenn Robinson, president and CEO of Hillcrest Health System in Waco. The entire staff will have to be retrained, not just coders. That’s because the new system will capture more information, meaning everyone involved in care will have to know what additional details to record, he said.

Also, the needed software upgrades and changes to forms and electronic records will be expensive, Robinson said. Estimates run from hundreds of thousands of dollars to millions of dollars per hospital, Robinson said.

In the long run, though, it will be worth it, Robinson said. For one thing, reimbursements should increase. The more detailed hospitals can be about the care they provided, the more they can get paid. Also, those details should help with quality and disease management, he said.

The increase in codes may seem like overkill, Robinson said, but medicine has evolved so rapidly that it is needed.

“It speaks to the marvelous changes in our industry,” Robinson said.

Todd Dorton, president and CEO of a Waco-based company that provides insurance consulting and brokerage services, said there is no denying new codes are needed to keep pace with industry changes. But he questions the enormity of the expansion.

Take angioplasty, Dorton said. It makes sense to develop codes that reflect what kind and how many stents are used during the procedure, for example, he said. But 1,170 variations?

“That’s ludicrous,” said Dorton, whose company is Fidelity Benefits & Insurance Services. “How does a doctor even know which of the 1,100 angioplasty codes are even available? . . . To me there is a way you could do this slower, something more measured.”

Having so many more codes is sure to lead to more billing errors, especially during the initial changeover, Dorton said. His company already sees dozens of incorrect explanation of benefits forms each week, he said.

The Wall Street Journal contributed to this story.

cculp@wacotrib.com

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