Turtle Bites and the Refutation of ICD-10 Criticisms

ICD-10 has been a hot topic of discussion lately. There are several important issues being hashed out by significant stakeholders in the Healthcare IT domain.  I’m not going to weigh in on each side’s specific points. Rather, I’m taking this blog down a slightly different road, as I’ve been both disheartened and disappointed by some of the criticisms regarding implementation of ICD-10. I feel compelled to debunk or otherwise invalidate criticisms of some of the ‘stupid’ or ‘outlandish’ codes that have been highlighted as superfluous, out of touch, or simply strange.

When I was in high school I had a pair of pet turtles.  They were Western Painted Turtles named Mortimer and Stella, and they lived in a 20-gallon turtle tank in my bedroom. They seemed happy enough and were kept in good health. I would hand feed them food pellets or strips of lettuce, and every so often as a treat they were given live feeder fish.  Turtles are slow, but when a delicious meal was swimming by they would quickly snap their mouths into the clueless fish. It was the most violent behavior I’d ever seen from them, but I was not scared. For all the times I hand fed them, I can’t say I’d ever been bitten.  I’d like to think that they wouldn’t have bitten me even if my hand was wrapped in lettuce.  Why then, does ICD-10 contain the code “W5921A – Bitten by a turtle, initial encounter”?  Maybe it was dumb luck or the turtles didn’t think I would taste good. I checked with my bulldog’s veterinarian (I had to give away the turtles when I headed off to college). I also have a friend in my apartment building that is (you may need to sit down for this) a doctor that keeps a turtle as a pet.  Both sources reported that they had no experience with, or knowledge of turtle bites, either directly or through hearing of such cases from their medical colleagues.  Surely code “W5921A” is a waste of space and shows how out of touch ICD-10 really is.

I live and work in downtown Boston – a place that can be considered a hub of Health Informatics – and it would be perfectly acceptable to assume that a turtle is not going to get me here. Yet, according to Wikipedia, the Common Snapping Turtle is indigenous to about 80% of the contiguous United States.  There are turtles all around me and they bite.

I live in an urban area – so what?  I thought some of the promise and potential inherent to the strides HIT has made over the past few years was to improve the quality of care provided to patients in more rural areas.  Take another look at the turtle map in the link above. Sure the U.S. has many great cities and urban centers, but there seems to be a good amount of rural communities covered as well. In ICD-10, physicians servicing those areas have a tool to help uniformly and accurately document and categorize the turtle bites they may see represented within their patient population.

Have we become so invested in taking a stand on ICD-10 that we’ve forgotten, literally, what it stands for? The first letter – I- is for ‘International’. ICD, whatever the version, is designed to be broad in scope and truly global in scale. It’s designed to encompass that which may be encountered (more on encounters later) beyond your own back yard, or state, or country.  There are people out there dismissing the viability of ICD-10 seemingly on the basis that a handful of codes doesn’t seem to apply to them.  I’m not going to mince words here: those ‘critics’ are both disappointingly narrow-minded and short-sighted. They don’t appreciate the potential value of the data that using ICD-10 will provide.  Truly, it saddens me that anybody in our modern world would chose to not be informed, and not have information at their fingertips, when it can so easily be made available.

Encoding the Universe

That last link above gave us a beautiful view of the planet Earth.  Interestingly, ICD-10 includes codes for describing injuries pertaining to the use of spacecraft. Surely these codes are entirely irrelevant.

‘Unspecified spacecraft accident injuring occupant…’ Yeah, ok, George Jetson. Tell your friends Paul Allen and Richard Branson to cool it!  Actually, you see, the age of space tourism and private space travel is already upon us.  It’s strangely ironic that an industry in the midst of its own technological revolution would find fault with the idea of including a dozen space related items in a list of tens of thousands.  ICD-9 was finalized in 1975 and published by WHO is 1977. Is it too much to ask that we get a little innovative and ‘future proof’ a standard? Ok, so maybe we won’t be flying around in personal spaceships that fold away into a briefcase, but progress is coming.  I will concede that it’s a bit cost-prohibitive. Paul Allen’s company, Stratolaunch, considers a cost of $63 Million to be competitive. Put things in perspective though, and realize that Ford’s Model T wasn’t exactly available for $89 per month with no money down during a July 4th Sales Extravaganza!

Space travel may not yet be affecting tens of millions of Americans, but you know what has? Swine Flu.  I’ve cited this excellent example in a previous blog post and refer to it again for precisely the same reason: ICD-9 originally did not have a way to specifically identify Swine Flu, yet it was responsible for the deaths of tens of thousands of Americans. ICD-10 does contain codes to describe Swine Flu, a type of influenza that literally seemed to appear out of thin air.  As we are deliberately going down the path of privatized space travel, is it really that out of this world to want a way to describe the injuries we might sustain as we push the boundaries of human exploration and experience beyond the reach of Earth’s gravitational pull? Are there really people who think we’d be better off lumping turtle bites, space-related injuries and swine flu all together as unknown? I certainly hope not.

Subsequent Encounters of the Wrong Kind

ICD-10 elicits a lot of strong opinions. Undoubtedly it is going to be a significant transition. No one said it was going to be easy for physicians, or coders, or executive management. There are valid criticisms of ICD-10…and then there are those from left field. One of the types of comments or criticisms that inspired me to write this blog post is the type that pertain to encounters.  I recall the mainstream media getting a chuckle at a code like this:

T7501XD Shock due to being struck by lightning, subsequent encounter

Wow, ICD-10 actually has a code to specifically classify when a person gets struck by lightning twice!  What are the odds that this is EVER going to happen? I’ll probably succumb to a billion turtle bites before ever being struck by lightning once, let alone a second time.

Wrong, for so many reasons.  First of all, according to the National Weather Service, There is a 1/10,000 chance of getting struck by lightning in your lifetime.  Those aren’t exactly impossible odds. People generally seem to think that getting struck by lightning or winning the lottery will never happen to them.  Surely, having such a remarkable occurrence happen to you is a once or a lifetime experience. Unfortunately, Roy Sullivan would probably disagree. I wonder if he ever played the lottery.

Now that I’ve shown it’s within the realm of possibility to be struck by lightning more than once, let’s take a closer look at that ‘subsequent encounter’ part of the description.  One of the biggest and most significant misconceptions inherent to the implementation of ICD-10 is the confusion that subsequent encounter means that ‘it happened again’.  In truth, that designation is meant to describe when the patient has received active treatment for the injury, and the physician is providing routine care for the injury during the healing or recovery phase (hcpro.com).

Curiously, if there actually was a person seeking medical treatment for having been struck by lightning more than once, wouldn’t that be of at least some clinical or scientific interest?  While I’ve gone over the actual significance of the ‘encounter’ concept, perhaps there should be a way to specifically document patients that have multiple experiences with somewhat uncommon diagnoses.  Surely there is some analytical or syndromic surveillance value in such a case.  Maybe in future versions – well beyond ICD-10.

Defending ICD-10 is making a case for innovation and ultimately, improved patient care.  While the code set includes dozens of examples for describing events that may not ever be recorded, it’s irresponsible to cast them away as useless.  Turtle bites, space ship accidents, and lightning strikes can and will happen. ICD-10 provides the scalability and flexibility to accurately document these incidents and the healthcare industry as a whole will be better for having this information available. My colleagues at Galen Healthcare Solutions and our partners at Allscripts will be ready to help when the time comes.

Disclosure: I am a member of both HIMSS and AHIMA.

Looking for some ICD-10 knowledge? Galen has a wide range of expertise around preparing organizations for the transition to ICD-10.

Sources: Turtle picture taken from the following url:


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  1. 1
    Harris R Stutman

    Very nicely expressed. I have made similar arguments on a number of medical informatics blogs, but feel I may be preaching to the choir. Nice to see others arguing “for the future”.

    Here’s an excerpt from one of my notes:

    The 2 biggest slams I hear right now are “off-base” in my opinion. One is the canard about 68,000 codes compared to 14,000 codes for ICD-9, as if any physician would need to be familiar with more terms (not codes) than she currently uses. In most cases the number of codes actually changes damn little: GI-related codes change from 530 to about 690, Respiratory codes from 230 to 325 or so and oncology from 950 to 1550, most of that related to laterality (and I think having the record include a structured distinction between cancer of the right adrenal and left adrenal seems like a good idea).
    The other is the one about being struck repeatedly by water skis while on fire. Beyond the misinterpretation of “subsequent episode”, the assembly of individual and consistent coded elements to create such humorous examples is a strength not a weakness – there being only one code signifying a certain type of injury, another code that for the source of the injury – trauma, burns, blunt force, etc., etc. The fact that one can now assemble these consistencies into myriad combinations, some of which are quite funny, is no more incongruent that the fact that one can assemble a Starbucks order into about 5000 different possibilities from about 8 variables (coffee type, size cup, flavors added, type of milk, temperature, extra shots or no, etc., etc.). [I stole that last example from the folks at Kaiser. I had been using the assembly of complex proteins, starting with only 4 DNA nucleotides, as a metaphor, but the coffee one is much better.]

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