ICD-10 Talk with Dr. Heidi Jannenga: How Many ICD-10 Codes Do I Really Need to Know?

November 6th, 2015
Codes, ICD-10, ICD-9, Insurance

Overwhelmed by the sheer size of the ICD-10 code set? Not to worry. As Dr. Heidi Jannenga explains in this edition of ICD-10 Talk, rehab therapy practitioners definitely don’t need to know every single code. In fact, they likely will stick to a few key subsets of codes. Which ones, you ask? Watch this video to find out, and stay tuned to ICD10forPT.com for all the latest ICD-10 news.



ICD-10 FAQ Part 4

November 6th, 2015
Codes, ICD-10, Transition

A few months ago, we started receiving tons of questions about the switch to ICD-10. So many questions that we quickly put together our first ICD-10 FAQ post, which we thought was the best darned thing ever (hence the title). But there was no satisfying your need for speed—er, answers. In fact, your questions about the code set switch started coming in even faster (unlike the healthcare industry’s transition to ICD-10, which was the slowest thing ever). Clearly, the impending coding change had folks feeling more than a little anxious, so we compiled a second and a third FAQ post. Even now, as ICD-9 (Tokyo) drifts further and further away, we’re still receiving tons of questions. Here are the answers to your most-pressing ICD-10 questions—for now, anyway:

Where do I find information on state regulations related to ICD-10?

We suggest contacting your payers, as well as consulting your state association’s website/state practice act, to get the most up-to-date, state-specific information.

What’s the difference between R53.1, Weakness, and M62.81, Muscle weakness (generalized)?

According to this resource, M62.81 is typically classified as a disorder characterized by a reduction in the strength of muscles in multiple anatomic sites, or a reduction in the strength of muscles in multiple anatomic sites. R53.1, on the other hand, is a sign or symptom associated with:

  • weakness and diminished or absent energy and strength;
  • debility, or lack or loss of strength and energy;
  • physical weakness, lack of strength and vitality, or a lack of concentration;
  • lack of physical or mental strength;
  • liability to failure under pressure or stress or strain;
  • weakness; and/or
  • lack of energy and strength.

If I shouldn’t use unspecified codes, then why are they even an option?

The unspecified codes exist in case there truly is not another, more specific option available. However, if a more specific option is available, you absolutely should use it.

If a patient experiences muscle weakness in a specific area, should I use M62.81?

The clinical description for M62.81 reads, “A disorder characterized by a reduction in the strength of muscles in multiple anatomic sites.” Because this code describes weakness in multiple anatomic sites, it would not be appropriate for weakness that exists in a specific location. As mentioned in our other FAQs, if available, you should always code for the underlying condition causing the muscle weakness first.

Can I list a condition like poor balance as a primary diagnosis?

You should code first for the underlying condition (i.e., what’s causing the patient’s balance issues). If you can’t determine the underlying condition, ICD-10 code R26.81, Unsteadiness on feet, might be a good option.

What code should I use for difficulty walking? R26.2 or R26.89?

Depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection.

For example, this resource explains that the description synonyms for R26.2, difficulty walking are:

  • Difficulty walking
  • Walking disability

The description synonyms for R26.89, Other abnormalities of gait, and mobility are:

  • Cautious gait
  • Gait disorder due to weakness
  • Gait disorder, painful gait
  • Gait disorder, weakness
  • Gait disorder, postural instability
  • Gait disorder, multifactorial
  • Toe walking and toe-walking gait
  • Limping/limping child

Should I code for accidents/incidents that affected my patients in the past?

You cannot—and should not—code for what you don’t know. If you can’t say for certain that the accident/incident directly correlates to the patient’s current condition, don’t code for it.

What if I have a highly-specific clinical coding question, and I can’t find the answer?

We’re happy to answer your questions to the best of our abilities. However, if the example is extremely clinical in nature, we can’t give you a definitive answer. But, we do know of a resource exactly for these types of situations. If you are able to supply supporting documentation for your particular scenario, you can submit your coding questions via this AHA portal.

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We’re more than a month into the so-far-so-good transition, but we expect the questions to keep coming faster and furious-er (um, yeah—something like that). And that’s OK. We’ve got you covered. Fast five, anyone?


From the Transition to Today: An ICD-10 Status Update

November 4th, 2015
ICD-10

The ICD-10 transition was feared and fought—and for many, it was fraught with concern over lost productivity and revenue. And that was all for good reason: the transition to ICD-10 was the biggest change most healthcare providers have had to face in their careers.

With so many unknowns, there was bound to be some kind of negative impact, right? That’s the mindset many members of the medical community carried into the transition, and it’s the reason healthcare systems, providers, and payers all over the US braced themselves for the potentially devastating ICD-10 earthquake by preparing, planning—and planning some more. And all of that preparation must have lessened the blow, because it’s already November, and we’re hardly feeling an aftershock. Some organizations have even described coding in ICD-10 as “business as usual.” Case in point: CMS announced on October 30 that they’re “pleased to report that claims are processing normally.” So with total mayhem averted, what does ICD-10 look like today?

The Numbers

Thanks to the millions of ICD-10 claims submitted every day, we already have some definitive data points regarding the number of denials and rejections—and the reasons behind them. Here’s what CMS has found so far:

Metrics
October 1-27
Historical Baseline*
Total claims submitted 4.6 million per day 4.6 million per day
Total claims rejected due to  incomplete or invalid information 2.0% of total claims submitted 2.0% of total claims submitted
Total claims rejected due to invalid ICD-10 codes 0.09% of total claims submitted 0.17% of total claims submitted
Total claims rejected due to invalid ICD-9 codes 0.11% of total claims submitted 0.17% of total claims submitted
Total claims denied 10.1% of total claims processed 10% of total claims processed

Nothing too shocking, right? Actually, the numbers seem pretty average compared to the historical baselines. But, can we really call the switch a smashing success this early in the transition?

The Waiting Game

Although the initial numbers look promising, some payers take up to 30 days to receive and process claims. That means we still have some time before we’ll know how the transition really went. In addition to the typical payer delays, Medicaid fee-for-service programs in California, Louisiana, Maryland, and Montana announced that they weren’t prepared for ICD-10—period. In this article, Charlotte Bohnett explains that “to work around this issue, those payers are accepting claims with ICD-10 codes, but then crosswalking the codes to ICD-9 in order to calculate reimbursements.” We’ve yet to see what kind of payment delays or inaccuracies will result from this messy workaround. But while we wait for the full payment picture to reveal itself, there are some things you can do in your own clinic to keep things running smoothly:

  • Make sure your staff members—including your front office employees, therapists, and billers—are communicating openly.
  • Figure out the reasons behind any incoming denials; then, work to prevent those types of denials in the future.
  • Audit and adjust your processes to improve productivity.

The Payment Delay Defense

When you focus on improving productivity and accuracy within your practice, your claims stand a better chance of getting paid—and paid quickly. But, how do you measure productivity within your own practice? “One suggestion to measure where your productivity is now is to look at your productivity by coder and/or type of coding from October 2014 through October 2015 to identify if any productivity loss exists, and if so, the percentage of loss,” explains this ICD10monitor article. “This should be a report that you run each month for the next 12 months, looking to make strides to get productivity back to what it was in 2014.” So, you need to not only evaluate your current claim denials, but also keep an eye on your productivity levels throughout the next year. This way, you’ll have a clear understanding of what delays and/or mistakes are holding up your revenue.

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So, what does ICD-10 look like for you today? Are you seeing dips in productivity? How about denials? Did the transition leave you running for the nearest door jamb, or did you feel barely a tremble? Send us an email using the form below to share your experience.


ICD-10 Talk with Dr. Heidi Jannenga: Am I Choosing the Right ICD-10 Code?

November 2nd, 2015
ICD-10, ICD-9, Insurance, Patient care

So, you’ve got the general gist of this whole ICD-10 thing. But when it comes to coding for specific patient scenario, you’re a bit less confident. How do you know if you’ve really picked the most accurate codes for a particular patient? In this video, Dr. Heidi Jannenga offers a few key pieces of advice for determining whether you’ve landed on the best possible code.



An ICD-10 Halloween Hayride Gone Awry

October 26th, 2015
ICD-10, ICD-10 Example

It was a dark and stormy night.

Ugh, seriously? Isn’t there a better way to set the scene? Let’s start this story over: It was a dark and hay-filled night.

There we go.

And a darling couple, donned in clever costumes, headed out to go on their very first hayride. Did we mention it was dark? Right. So, the couple headed out to their local farm to take part in the festivities (Y92.7, Farm as the place of occurrence of the external cause). And that’s where it all began. What began, you ask? The Halloween hayride—gone awry.

Leave the Hay for Horses

“Achoo!”

“Bless you,” said a kind person from the back of the hay bales. Our couple quickly discovered that hay really should be left for horses, because as it turns out, both of them suffered from J30.2, Other seasonal allergic rhinitis. With tissues in hand—and sneezes in tissues—they cuddled up for the hayride of their lives.

Keep Your Hands—and Heads—Inside the Vehicle

This warning typically ends with “at all times.” You may have heard—and heeded—this very rule while enjoying roller coasters, boat tours, or any other type of moving entertainment. But, our poor couple wasn’t paying attention to the hayride conductor as they both stood up to get a better view of the pumpkin patch. (On a side note, we’re not sure how this move helped them with their view—it’s dark outside, after all). That said, W22.8XXA, Striking against or struck by other objects, initial encounter, perfectly describes the wounds the couple sustained when their heads made contact with a wayward tree branch. Ouch.

Lift with Your Legs

With headaches in full bloom (G44.319, Acute post-traumatic headache, not intractable), the couple decided they’d trudge onward to pick out the perfect pumpkins. “He” (Let’s call him—uh—Jack) picked out an enormous squash—one he was certain would be the perfect companion for the neighborhood black cat that often graces his front stoop. He had big plans for this pumpkin—none of which involved carving it. Putting knife to pumpkin gives him the heebie jeebies. (His last name is O’Lantern, remember?). Did we mention the pumpkin was enormous? Great. Well, Jack reached down to pluck his perfect pumpkin when he heard a loud crack. Unfortunately, the sound wasn’t that of a prized squash pulled from the vine; it was poor Jack’s back, warranting a very vague diagnosis of M54.5, Low back pain. The pair would just have to continue on without a new stoop companion.

Don’t Eat Too Much Candy

Okay, so maybe our parents were right: too much candy can lead to more than just a sugar rush. (It could even lead to a game of candy crush, and nobody wants that. Trust me.) So, as Jack lay down in the back of the hay-filled truck, nursing his back, his lovely gal, Sugar Pie, munched on candy corn. Several handfuls later, Sugar Pie regretted her sugar binge. Her teeth rebelled, giving Jack’s sweet lady one heck of a toothache (K08.8, Other specified disorders of teeth and supporting structures).

Watch Your Back(side)

Our couple had quite the night, and it was almost time to go home. As the hayride approached the farm entrance, Sugar Pie gingerly held her jaw, Jack gripped his lower back, and the spider neither of them noticed crept closer to where they sat. Moments before Jack and Sugar Pie could hop out of the wagon, the spider swiftly sneaked up and bit Sugar Pie right in the rear (S30.860A, Insect bite [nonvenomous] of lower back and pelvis, initial encounter). Not quite the hayride-parting gift she’d hoped for, but a memorable memento nonetheless.

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The next morning, Jack and Sugar Pie reflected on their Halloween adventure as the sunrise shined on their round faces. Even though the hayride went awry, they had more fun than they could have imagined. With the black cat by their side, the two pumpkins looked out from their stoop and gave a deep sigh. The costumes, the candy, and even the injuries were too good to be true; their Halloween hayride had only been a dream (G47.9, Sleep disorder, unspecified).


ICD-10 FAQ Part Three

October 23rd, 2015
Codes, ICD-10, ICD-9, Insurance, Transition

We know that lots of good things come in threes—like three-piece suits, the Three Stooges, the three French hens your true love gave to you, and the number of sheets to the wind you might be after happy hour. And now, that list includes our ICD-10 FAQ series. In our first two pieces (here and here), we covered a lot of ground and—hopefully—gave you a good mid-level understanding of ICD-10. This third installment dives into the nuances of using the new code set to help you address some of your trickiest questions. So, let’s get to it:

General Questions

Does my treatment diagnosis have to match the diagnosis the referring physician sent? Sometimes my physicians don’t send codes with their referrals.

Your treatment diagnosis doesn’t necessarily have to match your referring physician’s diagnosis. With ICD-9, therapists typically used only the treatment diagnosis codes, leaving off the “true” diagnosis codes (i.e., medical diagnosis codes), because insurance companies only required treatment diagnosis codes for payment.

As the healthcare system shifts into a pay-for-performance environment—and with the introduction of alternative payment models—providers now must focus more on the complexity of the patient. And as far as claims go, the only way providers can communicate that complexity is through diagnosis codes. So, with ICD-10, it’s critical to include not only the treatment diagnosis codes, but also the codes for the medical diagnosis and comorbidities. This allows you to paint a complete, accurate, and detailed picture of the patient and his or her situation. Remember, though, that the primary code will still be your treatment diagnosis.

Thus, if your referring physician did not send a medical diagnosis, I would suggest reaching out to obtain one, as that will help ensure you code as thoroughly as possible.

When I get scripts with very generic instructions (e.g., “treat the legs”), is it okay for me to use an equally generic code (e.g., R29.9, Unspecified symptoms and signs involving the nervous and musculoskeletal systems)?

When you use generic—or in ICD-10 language, “unspecified”—codes, you risk payers inferring that your services are not medically necessary. So, it’s really up to you as to whether you’re willing to take that risk. We recommend either:

  1. reaching out to the referring physician to get more detail, or
  2. referring the patient to another specialist if, based on your clinical judgment, you believe the patient needs further evaluation that falls outside of your scope of practice.

In the ICD-10 code set, some codes have a dash ( – ) at the end of them. What does this mean?

The dash often is used in the note sections (e.g., Excludes1, Excludes2, and Code also). It indicates that the note applies to all of the codes in that series. That way, the codes don’t have to be listed out individually, which would take up a lot of space. So, to give an example, “T79.A-” would cover every single code that begins with “T79.A.”

Specific Coding Questions

How do I code for “X” patient with “Y” condition?

We’ve received numerous questions about how to code in very specific patient scenarios. However, because ICD-10 places such a strong emphasis on clinical judgment—which requires you, as the therapist, to select the most complete, accurate, and specific code(s) possible based on your assessment of the patient—we cannot provide coding advice for those scenarios. But, if you are able to provide supporting documentation, you can submit specific coding questions to this AHA portal.

What code(s) should I use to indicate decreased range of motion (ROM)?

While there are no codes for decreased ROM specifically, there are plenty of other codes that would apply to patients experiencing this symptom. For example, if a patient presents with decreased ROM in the knee, applicable codes may include those for difficulty walking or gait abnormality (R26.2 or R26.89), knee pain (M25.561 or M25.562), knee stiffness (M25.661 or M25.662), or knee effusion (M25.461 or M25.462).

I’m having trouble finding specific codes for conditions affecting the lumbar region (e.g., lumbar stiffness or decreased ROM in the lumbar spine). What are your suggestions?

While we are not trained coders, we can say that with ICD-10, you are encouraged to first code for the underlying condition causing such spinal symptoms. Here are a few resources that may help with coding spinal conditions:

What codes should I use to indicate muscle weakness in a specific anatomic location? The only muscle weakness code I can find is M62.81.

If the patient is experiencing weakness in one specific area, then the code for generalized muscle weakness (M62.81) likely would not be appropriate, as it indicates the weakness is present throughout the body. To code for weakness in a specific area, use the appropriate atrophy code (you’ll find many of these codes in the M62.5 code family). Additionally, keep in mind that the coding guidelines encourage you to code first for the underlying cause of the weakness, rather than the weakness itself. If you are able to do that, you can include the atrophy codes as secondary.

What ICD-10 code would you recommend for stiffness of the lumbar spine?

Whenever possible, you should first code for the underlying condition that is causing the symptom (which in this case is stiffness). Here is a resource that lists ICD-10 codes for common spinal conditions. As a secondary code, you could use M25.60, Stiffness of unspecified joint, not elsewhere classified (keep in mind that there is not a spine-specific option in that family of codes).

How do I code for impaired balance?

While there is not an ICD-10 code for impaired balance, there are several options that provide a much higher degree of specificity. These include the codes listed in the R26 (Abnormalities of gait and mobility) and R27 (Other lack of coordination) series. To select the code that best describes the patient’s condition, you’ll need to use your clinical judgment. You also may need to reference the coding synonyms provided in resources like this one.

Can I submit M54.5 (Low back pain) as a single, primary code?

Yes, M54.5 is a complete, billable code, and thus, you can use it as the primary. However, because it’s not a very specific code, you should only use it as the patient’s primary diagnosis code if there’s not a more specific code available to accurately describe the patient’s condition. If the patient has a confirmed underlying diagnosis (i.e., the condition actually causing the back pain), then you should code for that first. If not, then make sure you explain those details in your documentation.

I thought that the only seventh character options were A, D, and S, but I’ve noticed some codes have additional options (G, K, P, etc.). Is this a different seventh character system?

Yes. Codes for fractures use a whole different set of seventh characters:

  • A: Initial encounter for fracture
  • D: Subsequent encounter for fracture with routine healing
  • G: Subsequent encounter for fracture with delayed healing
  • K: Subsequent encounter for fracture with nonunion
  • P: Subsequent encounter for fracture with malunion
  • S: Sequela

You can learn more about fracture coding in ICD-10 here.  

External Cause Codes

If a patient doesn’t know what caused his or her injury, or if there’s no evidence that a specific event (e.g., a past car accident) resulted in the patient’s current condition, then do I need to use external cause codes?

You cannot code for what you don’t know. So, if you don’t know what caused the patient’s injury—or if there’s no definitive correlation between a known causal event and the patient’s current condition—then don’t code for it. Remember, external cause codes (like those that denote accidents) are optional. Just make sure you accurately record any potentially relevant information within the patient’s documentation.

I heard that S codes (i.e., injury codes) and M codes (i.e., musculoskeletal codes) cannot stand alone. What should I do if I don’t know any of the details necessary to select external cause codes (cause, location, activity, etc.)?

There is no blanket instruction regarding M codes and S codes being unable to stand alone. While you are encouraged to submit external cause codes when possible, they are not required. And if you do not know the details necessary to select those codes, then you shouldn’t submit them (in other words, you cannot—and should not—code for what you don’t know). However, you may see notes at the top of specific code categories instructing you to submit additional diagnosis codes with the codes in those particular sections (e.g., “Code also” or “Code first”).

The official ICD-10 coding guidelines state that external cause status codes, activity codes, and place of occurrence codes are “used only once, at the initial encounter for treatment.” Does that mean you only submit these codes on the claim for your initial evaluation of the patient?

Yes, according to the guidelines, you only need to submit those codes once, and that’s at the patient’s initial encounter (i.e., you initial evaluation). However, we have yet to see what will happen if those codes are submitted on subsequent claims. Different payers may have different rules, and some may enforce them more strictly than others. We don’t anticipate claims being denied for having “extra” codes; that said, if and when ICD-10-related denials start to occur, we’ll keep our Blog readers informed on the most common reasons behind those denials.

The above-cited coding guidelines excerpt seems to conflict with the excerpt that reads, “Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated.” I’m confused; should I submit external cause codes at every visit or just at the first visit?

Although Chapter 20 of the ICD-10 code set is titled “External Causes of Morbidity,” this chapter actually contains four different types of codes:

  1. place of occurrence codes,
  2. activity codes,
  3. external cause status codes, and
  4. external cause codes.

So, while you should report the main external cause code at every encounter, you only need to report the other types of codes at the initial encounter. Furthermore, “When applicable, place of occurrence, activity, and external cause status codes are sequenced after the main external cause code(s). Regardless of the number of external cause codes assigned, there should be only one place of occurrence code, one activity code, and one external cause status code assigned to an encounter.”

My billing system limits the number of codes I can submit. If I cannot submit all of the external cause codes that apply to a particular patient, how should I choose the one(s) I do submit?

Per the official reporting guidelines, “If the reporting format limits the number of external cause codes that can be used in reporting clinical data, report the code for the cause/intent most related to the principal diagnosis.”

Aftercare Codes

Should I always use an aftercare code for post-op patients?

Per the official ICD-10 coding guidelines (which you can find here), “The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character ‘D’ (subsequent encounter).” Based on those guidelines, if the surgery resulted from an injury that allows for the seventh character, you would use the original acute injury code with the seventh character “D.”

What is the difference between the aftercare codes Z48.89 (Encounter for other specified aftercare) and Z47.89 (Encounter for other orthopedic aftercare)?

Z48.89 applies to all types of surgical aftercare, whereas Z47.89 applies to orthopedic procedures specifically.

Can I submit a post-surgical aftercare code (e.g., Z51.89, Encounter for other specified aftercare) as the patient’s primary diagnosis code?

Your treatment diagnosis should be the one that best supports the medical necessity of your therapy services, and if you submit more than one treatment diagnosis code, you should order them according to significance. The ICD-10 coding guidelines seem to suggest that the order may change based on the specific context of the patient’s situation. The guidelines read: “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.” In other words, it’s up to you (and your clinical judgment) to determine which code best represents the main reason the patient needs therapy treatment.

If I am providing post-surgical rehab therapy treatment, and the patient’s original condition (i.e., the one that prompted the surgery) is no longer present, which codes can I submit besides the aftercare code?

If the condition that caused the patient to undergo surgery no longer exists, then you should not code for it. Instead, you can submit any applicable pain/symptom codes relevant to the patient’s treatment. Ultimately, the codes you use, and the order in which you submit them, are up to you and your clinical judgment. Just make sure your documentation clearly supports your coding choices.

Considering the degree of specificity ICD-10 affords, it seems strange that there are not surgical aftercare codes for specific surgeries (e.g., rotator cuff repair or ACL repair). How, then, should I code for these post-op patients?

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 in this case, would be D). So, if, for example, the patient 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. For more information on coding for aftercare, check out this blog post.

Claims

If I submit multiple diagnosis codes on a single claim, which one should I point to on my service lines?

You can submit up to four diagnosis code pointers per service line, which means you can point to up to four diagnoses.

If I have to resubmit a claim for a date of service prior to October 1, 2015 (meaning the claim contains ICD-9 codes), do I need to change the codes to ICD-10?

Because the transition to ICD-10 goes by date of service—not the date of claim submission—you should continue using ICD-9 codes for all claims with dates of service on or before September 30.

We bill electronically, and it is my understanding that we should be able to submit up to 12 diagnosis codes per claim. However, my billing software only sends the four top codes through to the claim. Why is that?

Because the standard HCFA claim form allows space for only four diagnosis pointers per service line, some billing systems only pull the four most relevant diagnosis codes through to Box 21 on the claim form. Those codes then become the origins for the four diagnosis code pointers that appear in Box 24E. We recommend looking for a billing system that allows you to send up to 12 codes through to Box 21; however, regardless of whether your system limits the number of diagnosis codes you can submit, it’s crucial that you order your codes according to significance, with those codes that most strongly support the medical necessity of your treatment appearing first.

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If ICD-10 is keeping you up at night, this post should help give you the guidance you need to get a few more hours of shut-eye. But, if our third ICD-10 FAQ wasn’t quite the charm, posit your ponderances to us using the form below, and we’ll do our darndest to answer them.


ICD-10 FAQ Take Two

October 23rd, 2015
ICD-10, ICD-9, Insurance, Preparation, Transition

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.)

General Questions

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.

Transitional Logistics

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 icd10_ombudsman@cms.hhs.gov.

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).

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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.

 


Life in the ICD-10 Lane

October 8th, 2015
ICD-10, Transition

ICD-9 was a hard-headed code set.
It was brutally outdated, and ICD-10 was terminally delayed.
The AMA held it up, and CMS held it for ransom in of the heart of the old, cold coding system.
ICD-10 had a nasty reputation as a complicated system.
They said it was ruthless; they said it was rude.
ICD-9 and ICD-10 had one thing in common: they are both to diagnose.
Providers said, “Faster, faster. My process is turning to dread.”
Life in the ICD-10 lane.
Surely, ICD-10 will make you lose your mind, mmm.
Are you with me so far?

Eager for action and hot for implementation.
The coming transition, the drop of productivity.
You knew all the right codes, took all the right courses.
You went through outrageous hoops, hopin’ to get paid.
There were service lines on the form, pointers on the claim.
You pretended not to notice, caught up in the race.

Diagnosing every evening, until it was light.
You were too tired to make it, but too tired to fight.
Life in the ICD-10 lane.
Surely, make you lose your mind.
Life in the ICD-10 lane, every code all the time.
Life in the ICD-10 lane, uh-huh.
Bummin’ and burnin’, blinded by specificity,
You didn’t see the date of service, took a turn for the worse.

I said, “Listen, baby. You can hear the diagnosis ring. We’ve been up and down this code set; haven’t seen a goshdarn thing.”
You said, “Call the doctor. I think I’m gonna crash.”
“The doctor say he’s comin’, but you gotta give him stats.”
You went rushin’ down that diagnosis,
Messed around and got lost.
Didn’t care, you were just dyin’ to get paid.

And it was life in the ICD-10 lane,
Life in the ICD-10 lane.

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So, the transition to ICD-10 has been a bit quiet so far. But, many of the implementation repercussions—like claim denials or payment delays—have yet to rear their heads. This means it could take several weeks—or even months—for providers to get a true sense of what it means to live life in the ICD-10 lane.


ICD-10: Beyond D-Day

October 1st, 2015
ICD-10, ICD-9, Preparation, Transition

D-Day was the beginning of a major turning point in World War II; for the healthcare industry, ICD-10 represents a major turning point for medical providers. No, the transition to ICD-10 isn’t a military operation—far from it, in fact—but both take a great deal of preparation and coordination to execute. Just like you wouldn’t attack your enemy without trained troops, skilled leaders, and a strategic plan of action, you wouldn’t make the transition to ICD-10 without preparation and coordination.

But despite best efforts, things don’t always go according to plan. Thanks to ICD-10’s increased demand for specificity, it seems there’s no avoiding a dip in productivity come October 1, 2015. As this AHIMA article explains, “Productivity loss, or an increased amount of time to code a patient encounter, due to the transition to ICD-10-CM/PCS is expected to reflect a bell curve, with the peak productivity loss surrounding the go-live date.”

But how will that slow-down actually manifest? According to this article from ICD10Watch, unfamiliarity with the new code set will cause decreased productivity in a few different ways:

  • Taking more time to find the correct code.
  • Spending more time communicating with physicians due to nonspecific referral diagnoses.
  • Claim rejections due to coding errors.
  • Delayed claim reimbursements due to payer unpreparedness.

While some factors are out of your control, the degree of productivity loss your clinic will suffer is mostly up to you. Here’s what you should focus on to combat productivity loss (as adapted from this resource):

  • Practice, practice, practice. If you use an EMR, take advantage of your vendor’s ICD-10 testing tool.
  • Make time for training (you’ll thank me later).
  • If it’s in the budget, consider hiring a coder (or two)—and make sure he or she knows how to code for your speciality.
  • Finalize all notes for dates of service on or before September 30—and submit any outstanding claims.
  • Examine—and refine—your systems and processes to maximize efficiency going into the transition.

Interested in figuring out how much productivity your clinic actually loses post-transition? You’re going to need to know your productivity levels as they currently stand. You should be tracking this already through key metrics, such as these metrics recommended by ICD10Watch:

  • Time to correctly code a medical claim
  • Time it takes to process a medical claim from patient encounter to healthcare payer
  • How long it takes for healthcare payers to answer coding questions
  • How long medical claims are in accounts receivable
  • Denial rates and how much money is denied
  • Difference between reimbursements and contracted rates

Once you have these figures, you can use them to compare productivity levels as time marches on. If you don’t have these metrics, it’s going to be a lot tougher to track and manage your decrease in productivity, but the war’s not over yet. You won’t have a baseline for your pre-transition productivity, but if you start keeping track now, you’ll at least be able to tell how your clinic is doing in the thick of the transition and, eventually, you’ll have data to demonstrate when your clinic begins to improve.

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ICD-10 is upon us, but if you attack it with all you’ve got, you’ll give your clinic a fighting chance. The transition won’t be easy, but if you keep your wits about you, you’ll come out the other side.