EDITORIAL

Is the Code Already Broken?

SURVEY OF OPHTHALMOLOGY VOLUME 53 � NUMBER 5 � SEPTEMBER–OCTOBER 2008

It used to be enough to make the diagnosis andprescribe the right treatment, but now physiciansare required to code both diagnoses and pro-cedures. The procedure codes, or CPT (CurrentProcedural Terminology), undergo almost constantrevision, but the diagnostic codes—ICD-9-CM (In-ternational Classification of Disease and RelatedHealth Conditions, 9th revision, Clinical Modifica-tion) are based on the World Health Organization’scopyrighted compendium that is over 30 years old.Imagine practicing medicine using journals ortextbooks that were a generation out of date.

The original ICD was an International List ofCauses of Death developed by Jacques Bertillon,Chief of Statistical Services of the City of Paris, andwas intended to improve mortality reporting. It wasadopted by delegates from 26 countries who met inParis in 1900. Revisions then occurred about every10 years. By the sixth revision, the need fora classification of morbidity was apparent, and thelist of causes of death evolved into the InternationalClassification of Disease. The latest revision, the10th, was accomplished in the 1990s, and is usedelsewhere in the world, but has not yet beenadopted in the United States.

Consider the following disorders discussed inrecent volumes of this journal, none of which havespecific ICD-9 codes: Purtscher’s and Purtscher-likeretinopathy (code as 362.83 cotton wool spot?),West African Crystalline Maculopathy, MultipleEvanescent White Dot Syndrome, arteriovenous

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communications of the retina (code as 743.9 un-specified anomaly of the eye?). Contrast this withsyphilis, which has dozens of codes: one, for example,for endocarditis of each of the cardiac valves (093.21-093.24) and many codes for its ophthalmic manifes-tations, e.g., retrobulbar neuritis (094.85), syphiliticuveitis (091.5-091.52), disseminated retinochoroidi-tis (094.83), optic atrophy (094.84), and of courseinterstitial keratitis (090.3). Older diseases haveadvantages over recently described entities, but notjust newly recognized disorders are ignored. There isa code for degenerative myopia (367.21), but not forhigh astigmatism (code as 367.20 astigmatism nototherwise specified?) or unilateral high myopia.

Nosology, the naming of disease, is a complicatedmatter, as I have previously pointed out in thisforum. As the ICD-9-CM was officially adopted in theHealth Insurance Portability and Accountability Actof 1996 (the now infamous HIPAA), it is enshrinedin legislation and has become difficult to change. Astime goes by, the nomenclature we are forced to usewill be increasingly outdated. While it can be arguedthat what we call something on a bill does notrestrict our thinking about disease, it seems a shamethat so much effort must be put into a flawedclassification.

John W. Gittinger, Jr., MDEditor-in-Chief

doi:10.1016/j.survophthal.2008.08.001

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0039-6257/08/$--see front matter