4 Tips for Preventing ICD-10 Denials—and Getting Paid

February 1st, 2016
EMR, ICD-10, Insurance, Preparation

For many practices, transitioning to ICD-10 has been no easy feat—especially considering the massive number of codes that are now available. Luckily, though, as a result of all the preparation leading up to the October 2015 go-live date, there haven’t been nearly as many claim denials as there could have been—or may be once Medicare’s grace period comes to end later this year.

So, whether you’ve already faced a denial or you’re wanting to get ahead of the game for when payers start enforcing stricter rules, here are four tips for preventing ICD-10 denials and ensuring you get paid:

1. Check your Codes

Whether you’re using an EMR or still documenting on paper (yikes), the responsibility for submitting the right ICD-10 codes for your patients ultimately falls on you, so take some time to double-check that the codes you should be submitting are the ones that actually are going through. You can do this by performing an internal audit to quality check your documentation against your claims. This is especially important if you’re using an EMR without an intelligent ICD-10 tool. If that’s the case, and you think the software has you covered, think again.

2. Be Specific

The whole point of implementing ICD-10 is to increase diagnostic specificity for patient data. So regardless of what payers are considering acceptable to process payments right now, they’re eventually going to require you to use ICD-10 to its fullest—and most specific—extent.

With that in mind, use this year to practice navigating to not only the right family of codes, but also the most specific codes you can identify that tell the complete story of your patients’ conditions—seventh characters and all. Just be sure that your documentation backs up the level of specificity your codes represent. As this Medical Economics article points out, you don’t want to be left repaying your reimbursement after an audit uncovers that your documentation doesn’t fully support your claim.

3. Do Your Research

The ICD-10 implementation deadline has come and gone, but that doesn’t mean you should stop learning about the coding system or how to navigate tricky coding situations. Rather, your best bet to prevent ICD-10 denials and ensure you’re getting paid is to stay up to date on as much ICD-10 news as you possibly can. Furthermore, you’ll want to keep a pulse on the changing requirements for each individual payer. After all, each insurance provider has its own set of claim specifications. As the above-cited Medical Economics article explains, “Payers may also want specific modifiers added or they may want a specific code used for a procedure.” In other words, you should “know what your payers want before you submit your claims.”

4. Switch to the Right EMR

Your EMR doesn’t need to brew your morning coffee, but it does need to help you stay ICD-10 compliant. Your EMR should do the following:

If your physical therapy software doesn’t do any of the above, then it’s time to replace it with one that does. And fast. ICD-10—as well as every other reporting regulation—only will continue to evolve, in terms of both complexity and intensity. Shouldn’t your practice be evolving with a more comprehensive compliance software, too?

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There you have it: Four tips for preventing ICD-10 denials so you get paid for your services. How has your practice been preventing denials? Fill out the form below and tell us your story.


How is CMS Resolving ICD-10 Issues?

December 7th, 2015
ICD-10, Insurance

The Centers for Medicare & Medicaid Services (CMS) recently announced that the transition to ICD-10 caused barely a blip on its radar. As it turns out, though, that optimism doesn’t outweigh the fact that there have indeed been issues on Medicare’s end—and they’ve caused more than a blip in providers’ workflows. Here’s what we know so far:

NCDs and LCDs

The “isolated” issues surround National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). This AACE document defines these terms as follows: “NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.” Translation: NCDs and LCDs outline allowable diagnosis codes for payment—which means that when there’s an issue affecting these policies, claims don’t get paid.

NCDs

In the case of NCDs, claims have been inappropriately rejected or denied. CMS has indicated it is committed to resolving these issues quickly. Specifically, the organization is:

  • automatically reprocessing wrongly rejected or denied claims (in most cases), without requiring any action or additional fees from the affected providers;
  • providing further clarification on, and refinement of, NCDs;
  • creating a permanent system to resolve issues by January 4, 2016; and
  • making information available on Medicare Administrative Contractors (MAC) websites.

LCDs

Some MACs failed to update certain LCD criteria, which resulted in additional errors. CMS is postponing processing these claims until the updates are complete. In the future, if any claims come in with these same errors, CMS will pause processing until the MACs make the required updates. If providers have any questions, they should contact the appropriate MAC.

Ready…

Before October 1, CMS made it a point to announce its ICD-10 readiness. Even back in July, the testing results touted success: “the agency stated that its last test run resulted in an 87 percent claims acceptance rate of the 29,286 tests the agency received. The rejection rate for ICD-10 errors was 1.8 percent and the rejection rate for ICD-9 errors was 2.6 percent.” Furthermore, CMS repeatedly assured providers that they had enough resources and staff to effectively handle the transition. In essence, CMS appeared to be totally prepared to tackle the transition.

Or Not

Now, it appears that CMS wasn’t as prepared as we’d all hoped—and believed. Plus, as this Healthcare Payer News article points out, “it’s worth keeping in mind that the government agency has taken several temporary steps to smooth the transition to ICD-10 which may be masking problems that could manifest themselves down the road.” Ouch. But, CMS isn’t the only entity that could encounter problems. This Healthcare Finance article also gives a grim forecast for providers: “Providers that considered themselves unprepared for ICD-10 as October 1 approached shouldn’t assume their currently low claims rejection rates mean their self-assessment was overly pessimistic. If they felt they were unprepared, they probably were. And if they were unprepared for ICD-10 on October 1, they probably still are.”

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As explained here, “CMS contractors have moved quickly to take action, such as temporarily suspending edits and/or claims, making fixes as quickly as possible, and reprocessing claims to minimize impact on providers.” That may be reassuring, but we’ve yet to see whether providers themselves were truly ready for the transition.

 


How Are Providers Handling the Switch?

November 20th, 2015
ICD-10, Insurance, Transition

So far, ICD-10 has arrived on the healthcare scene with very little fanfare. And we haven’t witnessed any major roadblocks or negative impacts on payers, claims, or payments. So with that in mind, how are providers handling the switch?

Productivity

One of the biggest fears providers had going into the ICD-10 transition was the potential for a huge loss in productivity. So far, though, providers haven’t reported any massive interruptions to their daily workflows. But, could that be because their claims haven’t been denied yet? As this Politico New York article explains, we’ve yet to see ICD-10’s true impact across the board: “One month into the transition to a new, expansive coding system for diseases and health problems, health care providers say it’s still too early to know what sort of repercussions the new system will have on their operations.” As more data comes in about claims and payments—or denials—providers will have a better sense of whether their productivity will suffer moving forward (i.e., how much time they’ll spend correcting and resubmitting claims).

Process

One aspect of ICD-10 that providers worked hard to prepare for was the inevitable change in their coding process. Because the new code set is much more specific, they had to adjust their coding habits to code more accurately. And in these beginning stages, it looks like their efforts are paying off—at least according to this RevCycle Intelligence article: “Nearly 1,000,000 ICD-10 claims were successfully processed the first time around within the first three weeks of October.”

But, to keep this momentum going, providers can’t kick back and get comfortable with their current habits. This Modern Medicine Network article stresses the importance of constant attention to detail and evaluation of processes: “Providers will continue to require coaching on documenting to ICD-10 level specificity and the importance of providing it from the time care is being authorized, all the way through the patient’s treatment plan.”

Potential

Even if there is a chance providers could suffer productivity loss in the future, they still stand to gain advantages from the ICD-10 switch. Because the new code set allows for more specificity, claims can be paid more easily—without the time-consuming back-and-forth communication between payers and providers. This Healthcare Informatics article explains that ICD-10 cuts down on “the ‘gigantic paper chase’ for providers, as historically commercial payers have frequently asked for more information or additional details about a procedure when providers submit claims.” So, as long as the transition continues as it has thus far, providers might find that ICD-10 offers more potential than it does pain.

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How’s the transition going for you? Are you seeing a drop in productivity? Or has your preparedness helped you take on this transition with ease? Fill out the form below and tell us about your experience, and keep an eye on the blog for more ICD-10 news as information is released.


ICD-10 News: Payers, and Clearinghouses, and Reimbursements—Oh, My!

November 11th, 2015
ICD-10, Insurance, Transition

“Business as usual” isn’t exactly what most providers expected to hear from The Centers for Medicare & Medicaid Services just a few short weeks after October 1. But, according to CMS, the transition to ICD-10 was just that: successful with nothing out of the ordinary. Of the estimated 4.6 million Medicare claims submitted every day, only 10.1% of those processed between October 1 and October 27 were denied. That’s just 0.1% more than the historical baseline number. But, even with numbers like these, has enough time passed for us to really gauge the transition’s success? Or are our assumptions a bit premature? Here’s the latest news:

Commercial

Emdeon, one of the largest claim clearinghouses, recently explained in an ICD-10 Watch article that “claims coded in ICD-9 for services before October are still coming in, but 86 percent of claims now being received at Emdeon are ICD-10.” So, even though the majority of claims contain ICD-10 codes, it might be too early to judge the situation with commercial payer reimbursements, because there are still ICD-9 claims lingering in many payers’ backlogs.

To add to the uncertainty, this Medscape Article reveals that some commercial payers took a page from Medicare’s “grace period” book and have been more lenient with denials based on code specificity alone. But how long will this leniency last? The article goes on to warn that “physicians and their billing staffs need to closely monitor the number and causes of denied claims going forward. Commercial insurers, after all, aren’t obliged to overlook specificity mistakes on matters like location and laterality as Medicare is doing.” So, there are no guarantees that payers will forgive specificity mistakes. And it may take weeks or even months to get a pulse on just how unforgiving these commercial payers truly are when it comes to denials.

Medicare

“Grace period” aside, Medicare payments are coming in at lower-than-average rates. That said, there’s no evidence that connects recent Medicare payment decreases with the transition to ICD-10. Health Data Management recently released an article that explains why: “Medicare payments on average are 7 percent less, but that is due to October payment policy changes.”

Even if these lower payments aren’t due to ICD-10, some providers might be experiencing other problems with Medicare and ICD-10. If that’s the case, CMS urges providers to:

Medicaid

If things seem to be going well for Medicare, the same must be true for Medicaid, right? Unfortunately, this is not a guarantee. Because Medicaid claims can take up to 30 days to be submitted and processed, we have very little information on whether these claims have been successfully submitted, denied, or paid. CMS has even announced they won’t have further news on Medicaid statistics until later this month, at the earliest. But, Mike Denison, senior director of regulatory compliance programs at Emdeon, says that that organization’s initial Medicaid claim data shows that the “average paid amount is 12 percent higher but denied payments—for several reasons that include a claim not meeting contractual policy or a subscriber is not recognized, among others—are down 9.6 percent.” Typically, Medicaid has the highest number of denials. So, why now are payment percentages up and denial percentages down? Maybe the grace period is making its mark in the Medicaid world. We won’t have a definitive answer until more time has passed and more claims have been submitted.

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Where does all of this information leave us? Analysis from RemitData found that “year-over-year data reveals that when you compare October 2014 claims processing figures to October 2015, only 24 percent of the anticipated claims volume has been processed for the month of October.” So, that means we still haven’t seen the full ICD-10 picture. However, I don’t think that means providers need to give up hope about seeing the fruits of their labor and preparedness; they just need to be patient. That’s because within the next 60 to 90 days, we might find that ICD-10 implementation is truly “business as usual.”


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 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.



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.

 


How ICD-10 Affects Your Claims

September 25th, 2015
CMS-1500, Codes, ICD-10, Insurance, Transition

There’s no doubt that the ICD-10 transition requires a huge shift in processes. But it’s not only your coding methodology that’ll change; your claims are going to look a little different as well. Here’s how ICD-10 affects your claims:

HCFA Forms are Ready

Wondering whether your beloved CMS 1500 forms are ready for ICD-10? Good news: the form was updated several years ago to account for ICD-10. This “new” form allows for up to 12 diagnosis codes—and you might just need all of those spots to accurately and completely describe a patient’s condition.

CPT Codes will Stick Around

If you’re an outpatient provider who uses CPT codes, you won’t need to change your procedural coding. You’ll continue to bill for the services you provide using the same codes you do now (e.g., 97001, 97110, and 97140). However, keep in mind that if you use superbills, you will need to update those to include ICD-10 codes. Finally, ICD-10 won’t impact the way you currently use any CPT-related modifiers (like KX or modifier 59).

One Service Line Allows for Four Codes

Remember the 12 available spots on the new HCFA forms? While you can submit up to 12 diagnosis codes on a single claim form, only four of those will map to a specific CPT code. That’s because the form only contains four diagnosis pointers per line. This is something that won’t change with the ICD-10 transition. Still, it’s important to include as many codes as you believe are relevant to your treatment.

Code Order Matters

When you’re dealing with multiple codes, you want to list them in order of importance. The first-listed code will be your primary code, which means it’s the code that most strongly supports the medical necessity of your treatment. Proving medical necessity is crucial when it comes to ICD-10; check out this blog post to learn more.

There’s no Minimum Number of Codes

For a claim to process correctly, it must contain at least one code. The number of additional codes you include is up to you. If you, as the clinical expert, believe one code accurately and fully describes a patient’s condition, then by all means, submit only one code. Beyond that, there’s no minimum of codes required on each claim.

Dual-Coding is a No-No

The transition to ICD-10 is determined by date of service. That means all claims with dates of service on or before September 30 must contain only ICD-9 codes, whereas all claims with dates of service on or after October 1 must contain only ICD-10 codes. The two can never appear together on the same claim. So, in order to avoid a dual-coding disaster, you may need to split your claims. Each payer will have its own claim-splitting requirements, so it’s important to check with that payer first before you determine how you’ll separate claims that span the transition date.

That said, some non-HIPAA-covered entities (e.g., workers’ compensation, and auto insurance) may not make the transition. So, you’ll need to continue to submit ICD-9 codes on the claims for those payers. We strongly suggest contacting your non-HIPAA covered payers individually to verify whether they plan to make the transition. Furthermore, as Lauren Milligan explains in this blog post, “Sometimes, you’ll see patients whose primary and secondary insurances require different code sets. In these cases, because you should include only ICD-9 codes on claims for payers who did not make the switch to ICD-10, you’ll need to split the claim and send each piece to the appropriate payer.”

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With these details in mind, give yourself a head-start by getting caught up on all of your billing prior to October 1. It may not be the easiest task, but it’ll save you a lot of headaches as you tackle the transition. And although not much will change in terms of how you complete and submit claims, you’ll be plenty busy adjusting your processes elsewhere. With the transition right around the corner, what are you doing to prepare?