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ICD-10: there's a code for that
Editorial
Jetta Productions/Blend Images/Corbis
ICD-10: there’s a code for that
For more on ICD see http://www. who.int/classifications/icd/en/ For more on ICD 10 in the USA see https://www.cms.gov/ Medicare/Coding/ICD10/ ProviderResources.html
The International Classification of Diseases (ICD) is the system for describing and coding mortality and morbidity incidents, implemented by most WHO member states. As of Oct 1, 2015, the USA formally transitioned to the updated codes, although they have already been in use in 117 other WHO member states (such as China and Canada) since release in 1992. The directive by the US Federal Government for ICD-10 compliance has been a major and controversial administrative and financial undertaking for health-care professionals, hospitals and health centres, and insurance companies. Notably, the American Medical Association (AMA) has been resolutely opposed to the upgrade, since the reforms will probably add a substantial burden of cost to medical practices and physicians, are administratively disruptive, and offer no benefits to patient experience. The change is considered necessary because of the inadequate and outdated coding offered by ICD-9, and the need for global consistency. The update from ICD-9, in use in the USA since 1979, has increased diagnostic codes
from 14 000 to 68 000 to describe the circumstances of injury, and includes almost all conceivable and unusual injuries such as: problems in relationships with in-laws; struck by an orca, initial encounter; and prolonged stay in weightless environment. The cost of the upgrade includes IT systems, which need to adapt to new medical records, an overhaul of data storage facilities, training for physicians and administrative staff, and loss of productivity. The AMA estimate that this cost will be around $86 000 for the smallest practice, to a range of $2–8 000 000 for a large practice. The Centers for Medicare & Medicaid Services has appointed a physician as ombudsman, and the AMA has set up an online facility to submit complaints directly to him. ICD-11 is due in 2018—other countries are already becoming prepared for this next wave. US consistency with the rest of the world is desirable, but the likely chaos and expense of the next few months will make many sceptical as to its necessity, especially beleaguered physicians already daunted by more complex reporting and reduced reimbursement. The Lancet
Godong/BSIP/Science Photo Library
HIV: the question is not when to treat, but how to treat
For the WHO guideline see http://www.who.int/hiv/pub/ guidelines/earlyrelease-arv/en/ For the START study see http:// www.nejm.org/doi/full/10.1056/ NEJMoa1506816 For the TEMPRANO study see http://www.nejm.org/doi/ full/10.1056/NEJMoa1507198 For the HPTN 052 study see N Engl J Med 2011; 365: 493–505 For Stefano Vella’s Addressing barriers to the end of AIDS by 2030 see Comment Lancet HIV 2015; 2: e360–61
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Last week, WHO expedited release of their Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV, ahead of the updated comprehensive guidelines scheduled for publication later this year. The early-release guideline recommends immediate initiation of antiretroviral therapy (ART) for all individuals living with HIV, irrespective of age and CD4 cell count. Previously, ART has been recommended only for individuals with CD4 cell counts less than 500 cells per μL (in addition to pregnant women, discordant partners, and those with other conditions such as active tuberculosis). Importantly, for the first time, the new guideline also supports provision of pre-exposure prophylactic interventions for all individuals at high risk of HIV infection. These recommendations are largely based on the results of the START, TEMPRANO, and HPTN 052 trials, which showed promising, but modest, benefits for affected individuals, and for reducing HIV transmission following early treatment initiation. In addition to the increased cost of treating all people now eligible for ART under the expanded criteria, specific strategies will need to be
implemented to diagnose the estimated 20 million who are unaware of being infected, including the currently underserved and difficult-to-reach populations, such as men who have sex with men, sex workers, injecting drug users, and transgender individuals. In The Lancet HIV, Stefano Vella discussed additional barriers—such as the risk of asymptomatic patients discontinuing treatment, as a result of having perceived no short-term benefits from ART—and calls for innovative community-based models of care to meet the UNAIDS goal of 90% retention on ART. The recommendations are welcome but ambitious. Whereas trials have shown that treatment can work as prevention, no studies exist that address how such a strategy can be executed on a global scale. By not specifying how the most vulnerable will access the recommended measures of health care, this guideline risks failing those most at need. With 2 million new infections occurring every year, treatment alone will not end the AIDS epidemic by 2030. A human rights-based approach that encompasses tailored combination HIV prevention must remain at the heart of the response. The Lancet www.thelancet.com Vol 386 October 10, 2015
Jetta Productions/Blend Images/Corbis
ICD-10: there’s a code for that
For more on ICD see http://www. who.int/classifications/icd/en/ For more on ICD 10 in the USA see https://www.cms.gov/ Medicare/Coding/ICD10/ ProviderResources.html
The International Classification of Diseases (ICD) is the system for describing and coding mortality and morbidity incidents, implemented by most WHO member states. As of Oct 1, 2015, the USA formally transitioned to the updated codes, although they have already been in use in 117 other WHO member states (such as China and Canada) since release in 1992. The directive by the US Federal Government for ICD-10 compliance has been a major and controversial administrative and financial undertaking for health-care professionals, hospitals and health centres, and insurance companies. Notably, the American Medical Association (AMA) has been resolutely opposed to the upgrade, since the reforms will probably add a substantial burden of cost to medical practices and physicians, are administratively disruptive, and offer no benefits to patient experience. The change is considered necessary because of the inadequate and outdated coding offered by ICD-9, and the need for global consistency. The update from ICD-9, in use in the USA since 1979, has increased diagnostic codes
from 14 000 to 68 000 to describe the circumstances of injury, and includes almost all conceivable and unusual injuries such as: problems in relationships with in-laws; struck by an orca, initial encounter; and prolonged stay in weightless environment. The cost of the upgrade includes IT systems, which need to adapt to new medical records, an overhaul of data storage facilities, training for physicians and administrative staff, and loss of productivity. The AMA estimate that this cost will be around $86 000 for the smallest practice, to a range of $2–8 000 000 for a large practice. The Centers for Medicare & Medicaid Services has appointed a physician as ombudsman, and the AMA has set up an online facility to submit complaints directly to him. ICD-11 is due in 2018—other countries are already becoming prepared for this next wave. US consistency with the rest of the world is desirable, but the likely chaos and expense of the next few months will make many sceptical as to its necessity, especially beleaguered physicians already daunted by more complex reporting and reduced reimbursement. The Lancet
Godong/BSIP/Science Photo Library
HIV: the question is not when to treat, but how to treat
For the WHO guideline see http://www.who.int/hiv/pub/ guidelines/earlyrelease-arv/en/ For the START study see http:// www.nejm.org/doi/full/10.1056/ NEJMoa1506816 For the TEMPRANO study see http://www.nejm.org/doi/ full/10.1056/NEJMoa1507198 For the HPTN 052 study see N Engl J Med 2011; 365: 493–505 For Stefano Vella’s Addressing barriers to the end of AIDS by 2030 see Comment Lancet HIV 2015; 2: e360–61
1420
Last week, WHO expedited release of their Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV, ahead of the updated comprehensive guidelines scheduled for publication later this year. The early-release guideline recommends immediate initiation of antiretroviral therapy (ART) for all individuals living with HIV, irrespective of age and CD4 cell count. Previously, ART has been recommended only for individuals with CD4 cell counts less than 500 cells per μL (in addition to pregnant women, discordant partners, and those with other conditions such as active tuberculosis). Importantly, for the first time, the new guideline also supports provision of pre-exposure prophylactic interventions for all individuals at high risk of HIV infection. These recommendations are largely based on the results of the START, TEMPRANO, and HPTN 052 trials, which showed promising, but modest, benefits for affected individuals, and for reducing HIV transmission following early treatment initiation. In addition to the increased cost of treating all people now eligible for ART under the expanded criteria, specific strategies will need to be
implemented to diagnose the estimated 20 million who are unaware of being infected, including the currently underserved and difficult-to-reach populations, such as men who have sex with men, sex workers, injecting drug users, and transgender individuals. In The Lancet HIV, Stefano Vella discussed additional barriers—such as the risk of asymptomatic patients discontinuing treatment, as a result of having perceived no short-term benefits from ART—and calls for innovative community-based models of care to meet the UNAIDS goal of 90% retention on ART. The recommendations are welcome but ambitious. Whereas trials have shown that treatment can work as prevention, no studies exist that address how such a strategy can be executed on a global scale. By not specifying how the most vulnerable will access the recommended measures of health care, this guideline risks failing those most at need. With 2 million new infections occurring every year, treatment alone will not end the AIDS epidemic by 2030. A human rights-based approach that encompasses tailored combination HIV prevention must remain at the heart of the response. The Lancet www.thelancet.com Vol 386 October 10, 2015