Rob Base and DJ E-Z Rock said, “It takes two to make a thing go right.” If that’s the case, then you can’t get more right than a second helping of our ICD-10 FAQ. (Missed part one? Check it out here.)
Will ICD-10 eliminate the need to provide extensive detail within patient documentation?
Absolutely not. While ICD-10 makes it much easier to communicate detailed diagnostic information via codes, the transition to the new code set actually will make detailed documentation even more important. CMS explains why here: “If complete information is not captured in clinical documentation, the result will be incomplete documentation for coding that then can impact revenues through delays, missed revenues, outcome measures that don’t clearly or accurately reflect the quality and complexity of the care that is being delivered.” Furthermore, if you don’t do your own coding (i.e., your practice has a coder), then it’s even more important that you provide all the details necessary for proper code selection within your documentation.
I run a cash-based clinic, so I don’t need to worry about ICD-10, right?
The only exceptions to the ICD-10 transition mandate are HIPAA non-covered entities. So, the only way a therapist would be exempt from the transition is if his or her practice qualified as a non-covered entity. Remember, if your patients submit invoices to their insurance companies for reimbursement, you’ll need to provide the appropriate diagnosis codes. And as of October 1, those codes must be ICD-10.
The Grace Period
What happens if Medicare rejects my claim because my ICD-10 code isn’t a valid code?
As explained in our first FAQ, even with Medicare’s grace period, providers still must submit a valid ICD-10 code from the correct family of codes. However, in the event that you submit an invalid code—and, as a result, receive a claim rejection—you will “have the opportunity to resubmit the claim with a valid ICD-10 code,” this CMS resource explains.
What is a “valid” code?
Often referred to as a “billable” code, a valid code is one that has been built out to the highest possible level of specificity. In other words, you’ve added as many characters as you can to the code—including a seventh character, if the code requires one. (For more on seventh characters, check out this blog post.) For example, the code M70 (Soft tissue disorders related to use, overuse and pressure) would not be a valid code, because additional specificity is possible. However, the code M70.11 (Bursitis, right hand) would be a valid code, because you cannot add any additional characters to that code to make it any more specific.
What constitutes a family of codes?
In ICD-10, “families” of codes are typically indicated by three-character headings. According to CMS, “Codes within a category are clinically related and provide differences in capturing specific information about the condition.” For example, M70 appears at the top of the family of codes for soft tissue disorders related to use, overuse, and pressure. All of the codes that are listed underneath that heading belong to that family of codes.
Because Medicare won’t reject claims solely for lack of coding specificity, does that mean that the current diagnosis coding specificity requirements set forth by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) will be more flexible in ICD-10? Will I be in compliance with NCD and LCD policy as long as my ICD-10 code is in the correct family of codes?
No. As explained in this CMS document, the grace period announcement “does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10.” That said, the transition won’t affect the expected level of specificity; in other words, you’ll code to the same level of specificity in ICD-10 that you did with ICD-9. There is, however, one very important exception to that statement: laterality. “LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side,” CMS notes.
Does Medicare’s grace period apply to Medicaid?
No. The grace period guidelines only apply to “Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule,” this resource explains, adding that the grace period “does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.”
Will commercial payers observe a similar period of flexibility following the transition?
The official grace period announcement only applies to claims billed under Medicare Part B. Thus, it’s up to each individual private payer to determine whether it will offer a period of flexibility and to define the parameters of that flexibility.
The Seventh Character
Is there any new information on the difference between “A” and “D” with respect to rehab therapy encounters?
This has been such a hot topic of debate that one of the attendees of a recent CMS national provider call brought it up during the Q&A portion of the meeting. Here’s the exact answer the CMS representative provided, as noted in this call transcript: “There is no specific hard set definition of what active treatment is. There are some examples that are given in the official guidelines, such as surgical treatment, emergency department encounter, and that type of situation. So they’re—it’s not an all-exhaustive list. But what I think is probably clearer is that for the subsequent encounters, usually those are where there’s routine healing or a problem with the healing.”
How do I know which seventh character to use for a chronic or recurrent musculoskeletal condition, like those found in chapter 13 (which contains the “M” codes)?
Seventh characters do not apply to the codes listed in chapter 13. Most of the seventh character-eligible codes that rehab therapists will use occur in chapter 19 (a.k.a. the injury chapter).
Coding for Aftercare
I was under the impression that aftercare codes should not be used as primary diagnoses. Is this true in ICD-10?
While you may have been discouraged from using aftercare codes (i.e., “V” codes), as primary diagnosis codes in ICD-9, that is not the case in ICD-10—at least not according to the official ICD-10-CM guidelines for coding and reporting: “Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter,” the guidelines read. Furthermore, regarding R codes such as the one for gait abnormality, the guidelines offer the following explanation: “Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.” So, as with a lot of ICD-10 guidance, the context of the patient’s situation appears to influence the order of the codes.
It doesn’t seem like there are a lot of codes available to represent specific surgeries. Why is that?
While there is not an aftercare code for every single surgery, in many cases, the proper way to designate the phase of treatment (i.e., indicate that the patient is receiving aftercare) is to code for the original acute injury and add the appropriate seventh character (which would be “D”). So, if, for example, the patient who underwent rotator cuff surgery had originally strained his or her right rotator cuff, you would indicate that you are providing aftercare by using the code S46.011D, Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter.
Using Multiple Codes
Shouldn’t the primary code be a symptom/complaint code (e.g., difficulty walking), because this code reflects the reason the patient came to therapy?
In some cases, your primary treatment diagnosis code can be a symptom code that reflects what you, as the therapist, are treating. For example, let’s say a patient with Parkinson’s comes to you because he or she is having difficulty walking. In this particular case, you could use a code from the gait abnormalities section (the R26 family of codes) as your primary treatment diagnosis because you, as the therapist, are not treating the Parkinson’s. However, if you are actually providing treatment for an underlying condition, you are encouraged to code for it first, if possible, because it better supports the patient’s medical need for your services. For a more in-depth discussion of coding for medical necessity, check out this blog post.
How should I order my codes?
You should submit the codes in order of significance with respect to medical necessity. For more details on using multiple diagnosis codes, check out this blog post.
Should I include codes for comorbidities?
You should include as many codes as necessary to explain the complexity of the patient’s condition to the fullest extent possible. Remember, though, that you cannot code for what you cannot diagnose (with respect to your scope of practice). For referral patients, we recommend working with your referring physicians to ensure you’ve accounted for as many pertinent diagnoses as possible—and that you’ve selected the most accurate, specific codes possible to represent those diagnoses.
Considering that the transition goes by date of service, will claims for dates of service on or before September 30 be paid if I submit them with ICD-9 codes after October 1?
Payers theoretically should be equipped to handle claims with pre-October 1 dates of service—and thus, ICD-9 codes—even when those claims are are submitted after October 1. However, we strongly suggest finalizing all notes for dates of service on or before September 30 prior to the transition on October 1. Why? Because there’s no way to know for certain that all payers will truly be ready to handle that distinction. So, just be aware that if you submit pre-October 1 claims after October 1, you may experience delays in payment or have to deal with appeals or claim resubmission for those dates.
How does the transition work for those billing inpatient services?
As CMS explains here, “…for inpatient facility reporting, date of service is defined
as the date of discharge.” So if, for example, a patient is admitted to the hospital on September 27, but he or she isn’t discharged until October 2, you would use ICD-10 codes on the claim. Conversely, if that patient is discharged on September 30, you would use ICD-9 codes on the claim.
How should I handle claims with dates of service that span the transition?
There are different rules for different settings and claim types. To review the requirements for each, check out this MLN Matters document.
Additional Help Resources
What’s the deal with the ICD-10 Ombudsman?
CMS has named an ICD-10 Ombudsman “to be a one-stop shop for you with questions and
concerns and to be your internal advocate inside CMS.” His name is Dr. William Rogers, and he’s a practicing emergency room physician who has been the director of CMS’s Physicians Regulatory Improvement Team since 2002. You can reach him at firstname.lastname@example.org.
Where can I go for specific coding questions?
The American Hospital Association (AHA) provides a portal where you can submit specific clinical coding questions here. If you take advantage of this free resource, keep these guidelines in mind:
- Do not ask the service to code your entire superbill.
- Do not send an entire patient record and ask for proper coding.
- Do not simply ask for the appropriate code for a certain disease or procedure.
- Do not ask about payments, coverage issues, or general equivalence maps (GEMs).
- You must submit supporting medical records documentation with your question.
- You must specify whether the question refers to a specific clinical setting (e.g., skilled nursing facility, home health, or a particular provider type/specialty).
There you have it: a second ICD-10 FAQ to make it outta sight. Don’t see an answer to your questions? Check out part three here.