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Comment by maweaver | Hacker News Reader

But why? I could understand from a treatment perspective the type of animal mattering (but even then initial vs subsequent encounters?). From a billing perspective, wouldn't it make sense to have animal bite exam fee, with possible additional charges for bandaging, stitches, rabies shot, etc based on doctor's discretion?

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Because these are world health organisation 'international disease classification' codes that are designed for population health study and happen to be used for insurance billing in the US.

There are requirements for some data to be reported to federal and international organisations. For instance, these codes are also used on death certificates I think, so they can track whether a lot of people are dieing of flu (primary cause) after contact with duck (qualifier) and there is a bird flu outbreak.

There are many coding systems - semi-standard extensions of ICD used to identify very specific types of cancer or the ontology based SNOMED which is rarely used as intended but none the less is becoming the standard.

These codes are used for billing in the US to some extent but also for lots of other things, they are just a standardized set of codes that hospital IT systems use to talk about what is wrong with patients so they can somewhat interoperate - and they are forced to use them by government because the vendors prefer walled gardens over interoperability.

But if an app developer in a different industry doesn't know the history behind it then a must be worthless.

They are funny though, I just thought people might like to know the context

That’s how it usually goes.

I’ve lost count of all these times a freshly onboarded dev, replacing the old one, decided the système was needlessly complex, nothing made sense, and it’d be easier to just rebuild everything from the ground up.

Only to end up with a similarly complicated nonsense, because the complexity actually was in the domain, and he knew nothing of it.

> Because these are world health organisation 'international disease classification' codes that are designed for population health study and happen to be used for insurance billing in the US.

This is the root of the problem. These codes should not be used for billing. That should be much more coarse. They bill you for visiting the GP. They bill you for a surgery. Adding the codes to the records is fine and good, but really should just be an internal detail that isn't that relevant to the patient.

>> I could understand from a treatment perspective the type of animal mattering

Rabies, which is not just animals but also predators (snakes) that eat animals with rabies. There is even a disease called "seal finger" that is linked to seal bites. And bats, all sorts of nasty stuff can come from bats.

Well, it employs a lot of people to have this complex billing. And whoever argued the need for it got to do some major empire building, maybe scored a promotion.

Medical billing is a dreary business. Check out https://www.reddit.com/r/CodingAndBilling/. It's not clear that anyone is _trying_ to build an empire out of this. More likely, they're trying to build a bigger trash heap to climb on top of.

No one got a promotion out of it. The USA adopted the WHO ICD code system for diagnoses on billing claims because it was good enough, and much easier than defining a whole new code system. Some of the codes are never used, but so what.

Because, like it or not, a doctor's discretion can sometimes be self-serving. The more treatments a doctor gives, the more they get paid, and there is an enormous information imbalance between doctor and patient. (As in, they went to medical school, and you didn't.)

Unfortunately, some doctors are willing to take advantage of this.

It's kinda ridiculous that because it costs x billion in doctors overcharging, we'll spend 100x on administration to control costs. Cutting off one's nose to spite one's face and all that.

I always preferred "The cure is worse than the disease." for a metaphor describing US healthcare billing.

Nobody actually wants to control costs. From doctors to hospitals to insurance companies, everyone but consumers benefit from high prices.

Employers and other group buyers want to control costs.

They are consumers

Employers are customers, not consumers. That word has a specific meaning in the industry and you are using it incorrectly.

Corporate entities consume administrative hours, paperwork, procedures, etc... of the healthcare system, which have many interested parties that benefit from that, they are consumers in a broader sense.

You're really missing the point. The word "consumer" has a specific meaning in the health insurance industry, which is what this article covers. What you're describing is irrelevant and off topic.

How is that 'off-topic'? That is the point of the parent, that many, including employers, corporate entities, etc., benefit from increasing consumption of the healthcare system.

Those are not consumers.

Did you misread my comment? Corporate entities certainly consume non-zero amounts of resources. They are definitely consumers in an economic sense. That applies for all sectors of the economy, not just healthcare.

Actually if you think about it insurance is forced investment in a fund where the amount they make is driven as much by the amount they can get you to pay in as much as efficiency. It is only beneficial not to be so obviously egregious that nobody will touch you in an environment full of people who are tacitly collaborating to increase prices so that the pie gets bigger for everyone.

Everyone is actually collaborating against you which is why in the US we only provide free health care for a small fraction of the populace but still manage to pay for THOSE folks as much as some other developed nations pay to cover their entire population.

And why this has not been prosecuted as giant racketeering operation is beyond me.

This has gradually changed with the emergence of "value-based healthcare", which is what we should be solving for (and building the right incentive structures for)

> The more treatments a doctor gives, the more they get paid

You could say this 30 years ago, but it's not really the case today. The majority of physicians are now salaried, not independent. And even for many of the ones in independent private practice, the amount they make is not necessarily tied anymore to the services they provide, due to the rise of capitation and other forms of bundled service agreements.

Nowadays, it's actually statistically more likely that you receive care from a doctor who has an explicit incentive to undertreat, because they receive a fixed amount of money per patient per year, and the costs of treatment come out of pocket directly with no additional reimbursement.

This is the basis of all Medicare Advantage Plans, where the physician or their employer gets X$ a month per MAP patient and must pay for most of the cost of care. The insurance company gets to keep most of its share of what Medicare pays. Nice profit ensues for the insurance company.

Insurance companies that sell Medicare Advantage plans end up keeping only a tiny fraction of what they're paid, hardly "most". This is a low-margin, high-volume business. You can find the details in their published financial reports.

I would love to see some data on this, if anyone knows of any. I'll just provide anecdata that of the doctors among my friends and family, more of them get paid by "wRVU" [0], which is basically a derivative of "how much treatment you give", than by salary.

(I only happen to know this because they complain nearly incessantly about the wRVU system! I make no claim to be an expert on the topic.)

[0] https://www.physiciansthrive.com/physician-compensation/wrvu...

> From a billing perspective, wouldn't it make sense to have animal bite exam fee, with possible additional charges for bandaging, stitches, rabies shot, etc based on doctor's discretion?

That is FFS (fee-for-service) billing. And indeed that does not use the diagnosis code, except for reporting purposes and documentation that the treatments were appropriate/necessary.

The diagnosis code would be used if billing in a DRG (diagnostic-related groups) model, which is an overall fee for overall treatment related to the condition -- exam, stitches, etc.

It partly arises as a mechanism to pay per case, not just per visit. For example, if we put all payment for a breast cancer treatment into the first visit, there is now an incentive to either complete the treatment (ideal) or keep the patient from coming back (less ideal). You can use these follow-up codes to measure rates of return visits, which can be related to quality of care metrics.

because CDC wanted to collect epidemiological data on how those bites were happening, instead of having single generic "animal bite" code. If there is a sudden rise in duck bites in a future decade, we can start asking about whether there's a reason behind that, or something we should be doing to control duck populations, or something. That's what CDC is there to do.

It's extraordinarily difficult to capture this information after the encounter... the patient is gone, the provider is working from notes/memory, and now it's this additional specific burden. How are you supposed to run an epidemiological study on the prevalence of duck bites if everyone involved has vanished into the ether? If you're going to capture it, it has to be rolled into the diagnosis codes and captured during the encounter. Also, you really want to capture the contemporaneous narrative including any misdiagnoses/etc - the CDC wants to know how much that is happening too!

really those low-level codes are kinda just there, they're not really used in practice, and most billing systems would care about the higher levels of the hierarchy anyway. The part insurance cares about is "cleaning and stitches after small wild animal bite", not the levels of the coding scheme that indicate that it's a duck bite.

(but you can see how it is potentially useful to shake some of these details out - is it a large animal, or a small one? a pet or a wild animal? a wild bear bite and a pet duck bite are two very different scenarios for the provider+insurer!)

It's also really more about things like "gunshot wound from stranger" vs "gunshot wound from partner" vs "gunshot wound from LEO" where there is obvious value in capturing what is going on. Jokes aside, nobody is super concerned about duck bites, it's just a funny example of how detailed the coding system can be (not must be... at least yet).

The real travesty is the idea that the same action using the same materials in the same facility can be billed 2 different ways based on two different ICD codes, not that ICD codes include the diagnosis data. It shouldn't matter if it's a duck or a cat, it's a superficial clean-and-bandage, that's what procedure coding (CPT) is supposed to capture. If there's major variations in how you perform a procedure based on how the patient presents, such that cost is substantially impacted... that is a deficiency in CPT and needs to be fixed independently, not forcing everyone to track CPT+ICD for eternity.

~~CPT itself incorporates a huge amount of nuance and sub-coding for this exact reason.~~ Simple example but we'd spit out CPT codes like "MRI with contrast-enhancer" vs "without", "MRI 3-tesla" vs "1.5T" vs "Open", "CT 64-slice" vs "40-slice", etc. If you're not capturing some aspect of the procedure you need to take it up with the CPT people, not make it everyone else's problem.

edit: superfun memory this just triggered, in fact this imprecision in CPT coding actually does lead to different things having the same CPT code and operators have to select from a picker of these possibilities that are specific to their organization's coding/billing systems. Forgot about that, awesome!

Medical data systems are the absolute worst

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