Laxmaiah Manchikanti, MD, is the chairman of the board and CEO of the American Society of Interventional Pain Physicians and the Society of Interventional Pain Management Surgery Centers; medical director of the Pain Management Center of Paducah (Ky.); and associate clinical professor of anesthesiology and perioperative medicine at the University of Louisville, Kentucky.
Q: What are some of the major issues facing pain management in regards to healthcare reform?
Dr. Laxmaiah Manchikanti: There are various issues for interventional pain management which are the same as the other areas of medicine. Specifically, these include coverage policies. Interventional pain management is not considered as an essential service, thus coverage is minimal.
Numerous other regulations whether related to healthcare reform or associated with it include mandatory transition to ICD-10, almost mandatory implementation of electronic health records along with a multitude of regulations and infection control practices associated with single-dose vials. These practices create a critical shortage of medicines and exorbitantly high costs. None of these activities improve patient care, rather they reduce it.
Q: How will ICD-10 affect pain physicians?
LM: ICD-10 will affect pain physicians substantially. There is a whopping 712 percent increase in codes; however, at the same time, there are 119 codes in ICD-9 which can map to more than 100 distinct ICD-10 codes, whereas there are 255 instances where a single ICD-9 code can map to more than 50 ICD-10 codes. The majority of the pain management codes do not map into such increased numbers; however, they do map into approximately five to 10 codes. Some codes such as spinal stenosis have approximately 30 ICD-10 codes. A physician has to think about and also use multiple codes if they are working just on the cervical spine instead of one code. There may be three different codes used for one treatment and one or two procedural CPT codes.
The worst situation is that multiple ICD-9 codes may be changed to one code. There are approximately 3,700 instances in the mapping for diseases where a single ICD-10 code can map to more than one ICD-9 code. As I have described related to pain management, post laminectomy syndrome, which is described by four codes now — 722.80, 722.81, 722.82, and 722.83 — will be converted into one code which is labeled as M96.1. This will create confusion and misunderstanding and no one will know which part was treated or which part is suffering. Especially if a person had surgery in the cervical spine, thoracic spine and lumbar spine and developed pain or post surgery syndrome in all three regions, you will still be using only one code. If you have to treat these patients separately with three separate interventions, you will be using only one code, and that will raise a red flag and confusion for quality as well as preparing for evidence-based management in the future.
Q: How will ICD-10 affect the management and development of evidence-based guidelines?
LM: Combining these codes will definitely hinder evidence-based medicine; however, increasing the number of codes may have a very minimum effect since the present codes already reflect significant differentials. ICD-10 has nothing to do with evidence-based medicine or justification. ICD-10 codes will actually cause confusion and ultimately it will be difficult to present evidence-based medicine because of the confusion.
Q: What will be the greatest challenges to providers?
LM: Providers will be bombarded with new information and new codes. It will be a whole learning experience, and may take several days to weeks to understand fully, and may not be perfected for years. To do this, it will be extremely expensive. Practices will have to develop resources, both human and financial. The estimated cost per physician is projected to range from $25,000 to $50,000; however, it may go upwards and the technology may have to be replaced every two to three years.
Other challenges are related to entering into an entirely different system one day. At this time you really cannot compare your old data with the new data. This will affect billing and coding training for personnel in these departments. Believe me, it will be very expensive. Even today, we use an extremely complicated system known as ICD-9-CM, which is in three volumes. This is not only used for disease classification, but it is also the standard for payment justification and supporting medical necessity for a procedure or a service provided to a patient in a health care setting.
Q: What are the advantages of the transition from ICD-9 to ICD-10?
LM: The major advantage of ICD-10 is effective reporting of morbidity statistics. However, no one knows how much benefit it has provided in other countries. There are numerous articles written describing its disadvantages.
For example, the Wall Street Journal on September 13, 2011, had an article which said, "Walked into a lamp post? Hurt while crocheting? Help is on the way." This article describes that today, hospitals and doctors use a system of about 18,000 codes to describe medical services and bills they send to insurers. Apparently, that doesn't allow for quite enough new ones. The Journal describes the new federally mandated [ICD-10] version that will expand the number to around 140,000 — adding codes that describe precisely what bone was broken or which artery is receiving a stent. It will also have a code for recording that a patient's injury occurred in a chicken coop.
Indeed, health plans will never again wonder where a patient got hurt. There are codes for injuries in an opera house, art galleries and nine locations in and around a mobile home, from bathroom to the bedroom.
Q: Does that information hold any clinical importance?
LM: This really does not hold any significant validity or value for clinical medicine. It may be useful epidemiologically by providing data on how people get hurt, etc.
Q: In the long-term, do you think ICD-10 will improve the quality of pain management treatment?
LM: Proponents are stating that it will improve quality. It may improve quality with regards to statistical analysis of morbidity. However, this will come at a very high cost. I do not believe that the improvement in quality is enough to put medical professionals through so much expense and cost during a time when regulations are exploding, numerous changes in healthcare reform are being implemented, reimbursements are being reduced and there is a lack of coverage for most of conditions except for essential conditions.
Q: What do you think should be done with ICD-10?
LM: ICD-10 should be postponed permanently. ASIPP is contacting the administration and members of Congress. This postponement will not only help practitioners and the entire medical profession, but also help the super committee to reduce significant federal outlays in implementing this. There are other issues related to improving care and access that we should focus on.
Q: What are those issues?
LM: The uninsured are escalating. For those who are insured, premiums are rising, coverage is reducing, co-pays and deductibles are increasing. Medical practices have to spend more and more to meet regulations and to implement healthcare reform, resulting in reduced reimbursement and increased work. The multiple other issues related to today's practice are infection control practices such as using single-dose and multi-dose vials for a single patient, which increases expenses by approximately four to five times for the drug costs, and also the ever increasing regulations and escalating costs of mandated electronic health records. These aspects are driving many practitioners out of business and to early retirement.
More Expertise from Dr. Manchikanti:
The Impact of Healthcare Reform on Interventional Pain Management
Dr. Laxmaiah Manchikanti: Where Pain Management is Now and Where Its Headed
Impact on Pain Management of the New Outcomes Research Institute: Q&A With Dr. Laxmaiah Manchikanti
Q: What are some of the major issues facing pain management in regards to healthcare reform?
Dr. Laxmaiah Manchikanti: There are various issues for interventional pain management which are the same as the other areas of medicine. Specifically, these include coverage policies. Interventional pain management is not considered as an essential service, thus coverage is minimal.
Numerous other regulations whether related to healthcare reform or associated with it include mandatory transition to ICD-10, almost mandatory implementation of electronic health records along with a multitude of regulations and infection control practices associated with single-dose vials. These practices create a critical shortage of medicines and exorbitantly high costs. None of these activities improve patient care, rather they reduce it.
Q: How will ICD-10 affect pain physicians?
LM: ICD-10 will affect pain physicians substantially. There is a whopping 712 percent increase in codes; however, at the same time, there are 119 codes in ICD-9 which can map to more than 100 distinct ICD-10 codes, whereas there are 255 instances where a single ICD-9 code can map to more than 50 ICD-10 codes. The majority of the pain management codes do not map into such increased numbers; however, they do map into approximately five to 10 codes. Some codes such as spinal stenosis have approximately 30 ICD-10 codes. A physician has to think about and also use multiple codes if they are working just on the cervical spine instead of one code. There may be three different codes used for one treatment and one or two procedural CPT codes.
The worst situation is that multiple ICD-9 codes may be changed to one code. There are approximately 3,700 instances in the mapping for diseases where a single ICD-10 code can map to more than one ICD-9 code. As I have described related to pain management, post laminectomy syndrome, which is described by four codes now — 722.80, 722.81, 722.82, and 722.83 — will be converted into one code which is labeled as M96.1. This will create confusion and misunderstanding and no one will know which part was treated or which part is suffering. Especially if a person had surgery in the cervical spine, thoracic spine and lumbar spine and developed pain or post surgery syndrome in all three regions, you will still be using only one code. If you have to treat these patients separately with three separate interventions, you will be using only one code, and that will raise a red flag and confusion for quality as well as preparing for evidence-based management in the future.
Q: How will ICD-10 affect the management and development of evidence-based guidelines?
LM: Combining these codes will definitely hinder evidence-based medicine; however, increasing the number of codes may have a very minimum effect since the present codes already reflect significant differentials. ICD-10 has nothing to do with evidence-based medicine or justification. ICD-10 codes will actually cause confusion and ultimately it will be difficult to present evidence-based medicine because of the confusion.
Q: What will be the greatest challenges to providers?
LM: Providers will be bombarded with new information and new codes. It will be a whole learning experience, and may take several days to weeks to understand fully, and may not be perfected for years. To do this, it will be extremely expensive. Practices will have to develop resources, both human and financial. The estimated cost per physician is projected to range from $25,000 to $50,000; however, it may go upwards and the technology may have to be replaced every two to three years.
Other challenges are related to entering into an entirely different system one day. At this time you really cannot compare your old data with the new data. This will affect billing and coding training for personnel in these departments. Believe me, it will be very expensive. Even today, we use an extremely complicated system known as ICD-9-CM, which is in three volumes. This is not only used for disease classification, but it is also the standard for payment justification and supporting medical necessity for a procedure or a service provided to a patient in a health care setting.
Q: What are the advantages of the transition from ICD-9 to ICD-10?
LM: The major advantage of ICD-10 is effective reporting of morbidity statistics. However, no one knows how much benefit it has provided in other countries. There are numerous articles written describing its disadvantages.
For example, the Wall Street Journal on September 13, 2011, had an article which said, "Walked into a lamp post? Hurt while crocheting? Help is on the way." This article describes that today, hospitals and doctors use a system of about 18,000 codes to describe medical services and bills they send to insurers. Apparently, that doesn't allow for quite enough new ones. The Journal describes the new federally mandated [ICD-10] version that will expand the number to around 140,000 — adding codes that describe precisely what bone was broken or which artery is receiving a stent. It will also have a code for recording that a patient's injury occurred in a chicken coop.
Indeed, health plans will never again wonder where a patient got hurt. There are codes for injuries in an opera house, art galleries and nine locations in and around a mobile home, from bathroom to the bedroom.
Q: Does that information hold any clinical importance?
LM: This really does not hold any significant validity or value for clinical medicine. It may be useful epidemiologically by providing data on how people get hurt, etc.
Q: In the long-term, do you think ICD-10 will improve the quality of pain management treatment?
LM: Proponents are stating that it will improve quality. It may improve quality with regards to statistical analysis of morbidity. However, this will come at a very high cost. I do not believe that the improvement in quality is enough to put medical professionals through so much expense and cost during a time when regulations are exploding, numerous changes in healthcare reform are being implemented, reimbursements are being reduced and there is a lack of coverage for most of conditions except for essential conditions.
Q: What do you think should be done with ICD-10?
LM: ICD-10 should be postponed permanently. ASIPP is contacting the administration and members of Congress. This postponement will not only help practitioners and the entire medical profession, but also help the super committee to reduce significant federal outlays in implementing this. There are other issues related to improving care and access that we should focus on.
Q: What are those issues?
LM: The uninsured are escalating. For those who are insured, premiums are rising, coverage is reducing, co-pays and deductibles are increasing. Medical practices have to spend more and more to meet regulations and to implement healthcare reform, resulting in reduced reimbursement and increased work. The multiple other issues related to today's practice are infection control practices such as using single-dose and multi-dose vials for a single patient, which increases expenses by approximately four to five times for the drug costs, and also the ever increasing regulations and escalating costs of mandated electronic health records. These aspects are driving many practitioners out of business and to early retirement.
More Expertise from Dr. Manchikanti:
The Impact of Healthcare Reform on Interventional Pain Management
Dr. Laxmaiah Manchikanti: Where Pain Management is Now and Where Its Headed
Impact on Pain Management of the New Outcomes Research Institute: Q&A With Dr. Laxmaiah Manchikanti