Happy ICD-10 Anniversary

October 14th, 2016
ICD-10, Transition

A little more than a year ago, tensions were high as the healthcare industry prepared for the transition from ICD-9 to ICD-10. After all, the threat of delayed—and denied—reimbursements was real. While Medicare committed to a one-year grace period during which it wouldn’t penalize providers for not using the most specific diagnostic codes available—as long as those codes fell into the correct code family—no one knew exactly how private payers were going to process the new codes (not to mention how providers and billers themselves were going to handle using such an enormous code set). Well, it turns out things went pretty well all the way around. Now, that’s something to celebrate. Here are some of the highlights from ICD-10’s first year:

More than 13 million ICD-10 claims were successfully processed in the first month.

According to this RevCycle Intelligence article, RelayHealth Financial reported that it had successfully processed more than 13 million ICD-10 claims—worth more than $25 billion—in the first 19 days of the transition alone. While there were some dips in productivity and a few workflow hiccups—a survey conducted in June by the American Health Information Management Association (AHIMA) found that overall coding productivity decreased by 14% and accuracy decreased by .65% after the transition—most providers reported that the “implementation process went smoother than expected.” This Healthcare Dive article echoes that sentiment. Michael Munger—a family physician with Saint Luke’s Medical Group in Overland Park, Kansas, and president-elect of the American Academy of Family Physicians (AAFP)—said, “The fear that this was really going to impact us financially because of the potential inability to process the new codes really never transpired.” Apparently, the AAFP tracks error rates, and it found that the error rate after the transition was the same as it was for ICD-9: 10%.

However, some EHRs weren’t holding their own.

Some providers did run into challenges with their EHRs. In the above-cited Healthcare Dive article, Richard Bruno—AAFP board member and resident in a joint family and preventative medicine program in Baltimore—said: “The challenge has been with the transition, especially within the medical records system, using the electronic health record and making sure that it’s searchable and that the right codes are associated with the right people, as these are tied to payment.” Munger’s practice actually had to upgrade its EHR recently in order to adapt to the greater level of coding specificity required after October 1, 2016. According to Healthcare Dive, Bruno believes that one of the major issues with the new code set is that it is “still tied to a fee-for-service billing structure that rewards [providers] for getting more detailed in their diagnoses.” He hopes that the move to more value-centric care and payment structures will help the entire process, because these new structures won’t hinge as much on “getting accurate diagnostic codes.”

And causation coding proved difficult.

While the challenges inherent to causation coding aren’t new—they existed in ICD-9 as well—many providers are finding it difficult to get the desired level of specificity in ICD-10 because they simply don’t have the necessary information. According to Barbie Hays—a coding and compliance strategist for the AAFP—“You can code out to it happened in a ranch style home or a split level…and there are some insurance companies that have started wanting that, but most are not.” She goes on to explain that there are opportunities for the Centers for Disease Control and Prevention (CDC)—and the ICD-10 governing committee—to provide additional guidance around the use of causation codes. However, it doesn’t appear to be high on their priority list right now, as they’re still focused on the codes for the injuries and illnesses themselves.

That being said, the AMA agrees that the transition went well overall.

The same Healthcare Dive article also reported that the American Medical Association—the organization that pushed CMS to institute the one-year grace period—believes the transition went well, as there was “no major uptick in Medicare claims rejections.” However, the AMA plans to continue monitoring the process now that the flexibility period has ended—as there’s still the possibility for “potential disruptions and changes that could result when more specific coding is required.”

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How did your clinic fare in the transition to ICD-10? Are you celebrating a successful year—or a challenging one? Tell us your experience in the comment section below.


Falling from Grace: How to Deal with the End of the Flexibility Period

September 26th, 2016
ICD-10, Preparation, Transition

It’s the end of September already, which means we’re only days away from the end of Medicare’s ICD-10 flexibility period—the year-long grace period in which CMS did not deny claims solely due to lack of code specificity. Beginning next month, though, the gloves are off—and, as a result, denials may increase. If you’ve been using this last year to become an expert on the nuances of the new code set—including how to use your clinical knowledge and documentation to select the most specific code available—then you may not even notice a change. If not, there are still a few things you can do to prepare. Here’s what you should know about the end of the flexibility period (as summarized from the Q&A portion of this CMS doc):

There will be no extension—and no phase-in period.

According to CMS, the grace period will end on October 1, 2016, and there will be no extension or phase-in period, because “providers should already be coding to the highest level of specificity.” The ICD-10 flexibility period was only put into effect so contractors performing medical reviews wouldn’t deny claims based solely on lack of specificity if there was “no evidence of fraud.” But, beginning October 1, providers must choose the most specific codes available—or risk claim denials.

CMS has three pieces of advice to help you prepare:

  1. Don’t use unspecified codes when a more specific one is available. (If you’re wondering how specific your codes should be, there’s no black-and-white answer. You must code to the highest level of specificity you can, while ensuring your documentation supports your coding choices—which brings us to number two.)
  2. Ensure your clinical documentation supports your code selections.
  3. Know that many major insurance carriers never implemented a grace period at all, which means many providers are already successfully using specific codes. In fact, according to a survey cited by CMS, providers have, for the most part, transitioned from ICD-9 to ICD-10 with little issue. (In other words, stay calm and carry on.)

Providers may still use unspecified codes—if the situation warrants it.

According to CMS, providers should report the most specific code available that’s supported by clinical knowledge and documentation. However, there are situations in which unspecified codes “are acceptable, even necessary”—such as “when sufficient clinical information is not known or available about a particular health condition to assign a more specific code.” CMS uses the example of a patient with a diagnosis of pneumonia: if no additional information is available to help the provider or coder determine the specific type of pneumonia the patient has, an unspecified code would be acceptable. To learn more about unspecified codes, check out these resources.

CMS is prepared to handle these changes.

CMS believes that the success of the initial ICD-10 transition proves that the organization is ready to handle new codes and processes. As such, they expect no delays with their enforcement of the post-grace period rules or the 2017 code update. This update includes the deletion of certain codes, the introduction of some new codes, and the revision of some code descriptions. “While this year’s update includes many new codes, the new clinical concepts are minimal,” CMS explained. The Center also notes that similar code updates occurred annually up until a freeze was established to help providers and payers prepare for the ICD-10 transition. As with any update, CMS recommends that providers:

  1. “Determine which codes affect their practices, and
  2. Focus on clinical concepts behind new codes.”

Audits will look just like they did before the ICD-10 transition.

As of October 1, 2016, CMS review contractors may deny claims due to lack of code specificity—and notify providers regarding issues and the steps necessary to correct those issues—in the same way that they did prior to the ICD-10 transition on October 1, 2015. To avoid audits, CMS says, “the provider community should code claims to the degree of specificity supported by the encounter and the medical documentation.”

There are more resources if you have questions.

For more ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website. There, you’ll find a complete list of the 2016 ICD-10-CM codes and code titles. You can also find the updated 2017 ICD-10-CM code set for services you provide on or after October 1, 2016, here. CMS updates the NCDs and LCDs whenever new codes are added. You can learn more about NCD updates on CMS’s ICD-10 website and LCD updates in the searchable Medicare Coverage Database.

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While some experts do expect an increase in denials following the end of the Medicare’s flexibility period, CMS doesn’t seem too concerned. How do you feel? Is your clinic prepared? Have you been coding to the greatest level of a specificity up to this point—or do you plan to up your game now?


3 Lessons Learned from the ICD-10 Switch

January 19th, 2016
ICD-10, Transition

This month, folks everywhere are making plans to get healthy in 2016. But, unlike many resolutions made in January, ICD-10 is here to stay. We’re already more than halfway through the month, and while gym-goers might start to slack, HIPAA-covered providers don’t have the option to drop the weight of ICD-10. Even if using a new code set isn’t exactly like a new year’s resolution, it’s definitely a new habit. And with any new habit comes a learning curve, and, inevitably, a few lessons learned. So, here’s what we’ve learned since the switch:  

1. Preparation pays.

You’ve probably read this—and, hopefully, experienced it for yourself: ample preparation across the healthcare continuum made the ICD-10 transition a success—so far. This ExecutiveInsight article highlights one piece of the puzzle: “The Centers for Medicare and Medicaid Services offered extensive education and testing services, while private payers and clearinghouses provided a framework for success.” But, it wasn’t just CMS, payers, and clearinghouses that worked hard to get ready for the switch. Providers, billers, and coders put in a tremendous amount of effort, too. They audited their processes, learned how to use the new code set, found solutions to coding and transitional challenges, and stayed on top of communicating with their vendors and payers. Hopefully, the healthcare community as a whole will remember this lesson as we come upon more changes—and challenges—in the future.

2. Mistakes happen.

Prior to October 1, many providers were confused about when to submit ICD-10 codes—especially for those patients with cases spanning the transition date. And after the transition, confusion quickly gave way to mistakes. For example: “Some providers coded ICD-10 based on the calendar date thinking that they needed to use the new ICD-10 code set for claims submitted on or after October 1. ICD-10 requirements actually call for providers to code ICD-10 on claims with dates of service or discharge on or after October 1,” explains the same ExecutiveInsight article. Now that we’re several months into the transition, these mistakes are steadily waning. However, that doesn’t mean practices should coast until another coding change comes around. This Government Health IT article explains the importance of remaining vigilant in auditing processes: “Payers and providers will be well-served by instituting a program for ongoing analysis that specifically compares their assumptions about the effects of the transition against the real time activity they are observing as claims accumulate over the next 12 months.” In summation: providers need to pay close attention to detail if they want to avoid making simple—yet costly—mistakes.

3. Communication is key.

While we’re a long way from achieving total interoperability, making the switch to ICD-10 was a step in the right direction. That’s because interoperability relies heavily on communication, and ICD-10 allows providers a simpler, more accurate way to communicate detailed patient diagnoses to other parties. But, communication isn’t solely about providing accurate and complete diagnosis codes; providers also need to communicate with their payers and even their software vendors to prevent simple misunderstandings. Many practices did a good job of doing just that in the lead-up to the ICD-10 transition. As for those who didn’t? Many of them ended up making mistakes—and suffering delayed payments as a result. So, the lesson here is that communication pays—literally.

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Like a good—and sustainable—habit, ICD-10 has given providers plenty of positive takeaways. And for those practices that embrace the changes that lie ahead with a positive mindset and a willingness to put in some effort, the future looks bright for many new years to come. Have you learned any ICD-10 lessons? Fill out the form and tell us your story below.


So, You Switched to ICD-10. Now What?

December 3rd, 2015
ICD-10, Transition

On September 30, 2015, healthcare providers all over the US were partying like it was 1999, but October 1 came and went—and for most folks, nearly nothing bad happened. We’re still in the early stages of the switch, so we can’t say for sure that it’s smooth sailing ahead, but if you felt like the transition to ICD-10 was more “calm waters” than “catastrophe,” you’re certainly not alone. PR Newswire announced this week that 79% of 298 organizations surveyed on November 9, 2015, by the tax, audit, and advisory firm KPMG LLP said the transition “has proceeded smoothly.” Here’s a more detailed breakdown of those responses:

  • 28% indicated they experienced a completely smooth transition.
  • 51% indicated they experienced a few technical issues, but were successful overall.

However, it wasn’t all clean claims and speedy payments, as 11% of respondents indicated their ICD-10 transition was a total failure.

Growing Pains

While it’s certainly a far cry from the doom and gloom many providers predicted, if you’re one of the 11%, you’re probably feeling a bit doomy and gloomy, thanks to some—or all—of the transition’s biggest challenges, including:

  • Rejected medical claims
  • Clinical documentation
  • Physician education
  • Reduced revenue from coding delays
  • Information technology fixes

But the transition to ICD-10 doesn’t have to be a death knell for your practice. After all, other clinics are hitting it out of the park—and you can, too. So, now what?

Moving Forward

According to this recent Managed Healthcare Executive article, the keys to success moving forward are:

  • tracking your key financial and operational performance indicators;
  • making timely, decisive actions;
  • keeping a pulse on the morale of your most impacted employees;
  • showing leadership and support; and
  • focusing on communication.

Furthermore, “providers will need to dedicate more attention to the quality and specificity of clinical documentation to reduce rejected medical insurance claims.” But that doesn’t tell you anything you don’t already know, right? There are several ways to handle this post-switch period, so what’s your first priority? Well, like 46% of survey respondents, you can tackle auditing your internal processes and systems, including:

  • Clinical documentation
  • Revenue cycle management
  • IT systems
  • Electronic health record system

That last system, in particular, plays a huge role in your ICD-10 transition—for better or for worse. As one provider reminds us in this Medical Economics article, “You learned ICD-9; you can learn 10 and with technology it is easier.” Another provider echoed that sentiment, advising healthcare professionals that “there are better tools available for dealing with these codes” and telling them to “ask your [EMR] vendor whether they can provide them.” My advice? If your vendor can’t offer what you need to be successful, find one that can.

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Okay, so that’s a good place to start, but keep in mind there’s a lot more to the ICD-10 transition than just optimizing your processes: there’s much to learn—and unlearn—and that’s no simple task. It’ll take time and effort, but your practice can make a full recovery from the transition to ICD-10. You’ll be back on your feet—and in the black—faster than you can say ICD-11. (Too soon?)


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 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?


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.