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Coding Corner: ICD-10 raises the diagnosis coding stakes on Oct. 1



September 01, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   


The first annual update for the ICD-10-CM code set becomes effective October 1, 2016, bringing with it over 1,900 new diagnosis codes and many hundreds of code revisions and deletions. More concerning, however, the same date marks the end of the ICD-10 coding “grace period,” which may significantly affect payment for your Medicare claims.


When ICD-10 became effective October 2015, the Centers for Medicare & Medicaid Services (CMS) granted a concession to ease the transition from ICD-9. For one year, CMS said it would not reject or audit Medicare Part B claims based solely on diagnosis coding, as long as the ICD-10 code(s) submitted were from the appropriate code family. In other words, “close enough” was good enough, and claims would be paid even if a provider’s diagnoses lacked the level of specificity that ICD-10 requires.


For example, within ICD-10 the three-digit code M05 describes “Rheumatoid arthritis with rheumatoid factor.” The code requires a fourth digit to describe potential complications (e.g., Felty’s syndrome, rheumatoid lung disease, etc.); a fifth digit to describe joint involvement; and a sixth digit for laterality (e.g., left, right or bilateral). Within the one-year grace period, a provider could correctly diagnose and code rheumatoid arthritis with rheumatoid factor but assign the fourth, fifth and sixth digits incorrectly—or not at all—and still receive payment from Medicare.


The upcoming end of the ICD-10 grace period means that Medicare will reject claims that lack diagnosis accuracy and specificity, which could affect reimbursement. Per CMS, “providers should already be coding to the highest level of specificity…. As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.”


Rather than wait until denials pile up, providers must be proactive to document diagnoses and assign diagnosis codes correctly. CMS advises that providers determine which codes affect their practices, and focus on clinical concepts behind those codes. For instance, to return to the earlier example of rheumatoid arthritis with rheumatoid factor, the relevant clinical concepts are related complication, joint involvement and laterality. If the provider documents those key concepts, selecting a detailed diagnosis is straightforward. But if any of those concepts are missing, the claim faces rejection.


Make a list of the most common diagnosis “families” in your practice or facility, and determine which clinical concepts are required to document those conditions to the greatest level of specificity. If you’re using an electronic health record (EHR), be sure your software is up to date and able to handle the code changes scheduled for Oct. 1. When properly designed or customized, the EHR may be able to prompt the provider to supply necessary details to support code specificity.


CMS also advises against assigning “unspecified” ICD-10 codes “whenever documentation supports a more detailed code.” Unspecified codes are appropriate only when a greater level of detail cannot be determined:


You should code each health care encounter to the level of certainty known for that encounter. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).


Check the coding on each claim to make sure that it aligns with the clinical documentation. For example, examine individual instances or patterns of unspecified code use so you can determine what information or steps you’re missing to assign a more specific code.


If you’re holding onto ICD-9—for instance, using General Equivalence Mappings (GEM) to “translate” your most common ICD-9 codes to ICD-10—it’s time to move on. GEMs cannot always translate accurately from one code set to another (and in many cases, no such translation is possible). It is both more accurate and more efficient to assign ICD-10 codes directly from the record.


Assigning diagnoses to the highest level of specificity takes time, but productivity will improve as providers and their staff become more familiar with the code set. And, by documenting completely and choosing codes correctly the first time, providers can limit the (far greater) time and expense of rejected claims, amending or correcting documentation and claims after the fact, payment appeals, negative audit results and more. 

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