Life in the ICD-10 Lane

October 8th, 2015
ICD-10, Transition

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It was brutally outdated, and ICD-10 was terminally delayed.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

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

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

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

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

__________________

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


ICD-10: Beyond D-Day

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

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

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

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

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

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

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

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

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

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

______________________

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


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.”

_____________

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?


Will ICD-10 Eradicate Paper Superbills?

September 21st, 2015
ICD-10, ICD-9, Transition

To a regular person, the idea of doing away with something called a superbill might sound alluring. I, for one, would love to trash the supersized energy bill I received after running my air conditioner throughout the month of August in Phoenix. For healthcare providers, however, the term “superbill” has a whole different meaning: it’s “a form used by medical practitioners and clinicians so they can quickly complete and submit the procedure(s) and diagnosis(s) for a patient visit for reimbursement,” explains the American Academy of Professional Coders (AAPC).

Many ICD-10 prep resources—including ICD10forPT—have encouraged providers to create ICD-10 versions of their current ICD-9 superbills, an exercise that:

  1. Helps practitioners get comfortable with navigating the ICD-10 code set, and
  2. Produces a helpful ICD-10 resource specific to each individual practice.

But while converting your ICD-9 superbill to ICD-10 is a great way to learn the ICD-10 ropes, it definitely shouldn’t be your only training activity. Furthermore, keep in mind that paper superbills won’t carry nearly as much weight in the post-ICD-9 world. In fact, relying on a superbill to guide your practice’s coding decisions likely will be a losing strategy with ICD-10. Here’s why:

1. Many ICD-9 superbills contain general codes.

In the interest of saving space, most superbills feature a hefty portion of “unspecified” or “not otherwise specified” ICD-9 codes. And while those codes might be enough to generate payment now, they’re just not going to cut it after the big switch. After all, one of the driving forces behind the move to ICD-10 is the global call for greater detail when coding patient diagnoses. For that reason, “ICD-10 requires you to code to the highest possible level of specificity,” explains this blog post. But mapping one general code to another defeats the purpose of the transition—and, more importantly, puts your practice at risk for denied payments.

2. Crosswalking tools often map ICD-9 codes to non-specific ICD-10 equivalents.

For the superbill conversion strategy to work well in practice, you’d need to find a single ICD-10 code to sub in for each ICD-9 code. And I hate to be the bearer of bad news, but you don’t have a snowball’s chance in the Sonoran Desert of doing that—at least not in a way that would meet the aforementioned specificity standard. In fact, in many cases, the quest to find a one-to-one match for a fairly specific ICD-9 code will actually lead to a less-specific ICD-10 code. The AAPC offers the following example to illustrate this point: CMS’s crosswalk maps the ICD-9 code 845.00, Sprained/strained ankle, unspecified, to both S93.409A, Sprain of unspecified ligament of unspecified ankle, initial encounter, and S93.409D, Sprain of unspecified ligament of unspecified ankle, subsequent encounter. “However, this is incomplete because it does not include a code for a strained ankle,” the article points out.  

3. More coding specificity means more codes.

Superbills are meant to be quick resources, and the ones currently in use probably don’t have enough room to accommodate all relevant ICD-10 codes. That’s because, as this ICD10forPT article states, “…for each ICD-9 code, there could be dozens—sometimes even hundreds—of possible ICD-10 equivalents.” And there’s no way to know which one to use until you have a real, live patient in front of you, because you’ll need to have a complete picture of the patient’s situation in order to select the code that most accurately represents his or her specific diagnosis. So, while your incumbent superbill might fit nicely on one page, your ICD-10 version could explode to nearly ten pages—or even more. As Gayl Kirkpatrick, a solution sales executive for 3M HIS Consulting Services, tells Government Health IT in this article, “We took a two-page superbill in ICD-9 and translated that into ICD-10…It became a 48-page superbill.”

4. Paper is so last-millenium.

The transition to ICD-10 represents a huge step forward for the entire US healthcare industry. This is the code set of the future (of the present, actually—after all, we’re the last major country in the world to take the ICD-10 plunge). It’s not just about us; it’s about collecting and analyzing data to raise the bar for patient care on a global scale. And to do that, we have to move away from the paper systems of old and embrace the technology that will usher us into a new age of health care. Who needs a printed list of codes when they have innovative, intuitive coding tools at their fingertips—tools that allow them to approach coding in a wholly patient-centric way? When you think about it that way, paper just can’t compete.

 

While paper superbills probably won’t disappear as fast as popsicles at an Arizona summer picnic, they will become less useful—and less reliable—come October 1. Looking for a better way to streamline diagnosis code selection? Click here to see a solution that puts paper superbills to shame.    


The Best Darn ICD-10 FAQ for PTs

September 14th, 2015
CMS-1500, Codes, ICD-10, ICD-10 Delay, ICD-10 Example, ICD-9, Preparation, Transition

If you’re a HIPAA-covered medical professional, ICD-10 is a huge deal for you—like, deflategate huge. Along with all the controversy—including delays and grace periods—ICD-10 also has caused a lot of confusion. Over the course of the months leading up to the October 1 transition, we’ve received thousands of questions regarding the new code set. After sifting through your coding queries, we’d bet good money that thousands more folks have questions, but they’re afraid to ask. That’s why we gathered our very best answers to your most-frequently-asked questions and created this hefty, Costco-sized collection:

The Seventh Character Craze

What is the seventh character?

The seventh character didn’t exist in ICD-9, so it’s caused a great deal of confusion. Basically, it’s a mechanism for applying greater specificity to a diagnosis, particularly with regard to the episode of care. As its name would suggest, the seventh character should always be the seventh digit of a code. As this blog post details, there are three seventh characters related to the episode of care:

  • A (initial encounter) describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause.
  • D (subsequent encounter) describes any encounter after the active phase of treatment, which is when the patient is receiving routine care for the injury during the period of healing or recovery.
  • S (sequela) indicates a complication or condition that arises as a direct result of an injury.

How do I know when to use the seventh character?

You don’t always need to attach a seventh character to your diagnosis code. Seventh characters are required for codes in certain ICD-10-CM categories—primarily Chapter 19 (Injury, poisoning and certain other consequences of external causes) and Chapter 15 (Pregnancy, childbirth and the puerperium). You’ll know when to use it because there will be instructions specifying seventh character use within any code book or tabular list you reference. Don’t see instructions? Then “leave the seventh position blank,” explains this blog post. “Adding a seventh character to a code that does not require one will make the entire code invalid.”

What’s the difference between A (initial) and D (subsequent)?

We’ve seen multiple interpretations of what distinguishes an “initial encounter” from a “subsequent encounter.” Based on everything we’ve reviewed, this is the best answer we’ve found: “The 7th character for ‘initial encounter’ is not limited solely to the very first encounter for a new condition. This 7th character can be used for multiple encounters as long as the patient continues to receive active treatment for the condition.” This resource goes on to say: “The key to assignment of the 7th character for initial encounter is whether the patient is still receiving active treatment for that condition.”

So, it appears that the words “initial” and “subsequent” have less to do with how many practitioners the patient has already seen or how many visits the patient has logged at your office, and more to do with the patient’s treatment phase (i.e., “A” for active treatment and “D” for recovery/healing). That would mean the “A” designation wouldn’t be limited to the patient’s first visit, even though the label “initial encounter” makes it seem like a one-time descriptor.

What about sequela (S)?

According to Code It Right Online, “‘sequela’ in ICD-10-CM, is a chronic or residual condition that is a complication of an acute condition that occurs after the acute phase of a disease, illness or injury. It can also be caused indirectly by the treatment for the disease or condition.” There’s no time limit on when you can use sequela; “the residual condition may come directly after the disease or condition, or years later.” Simply put, this less frequently-used character is reserved for complications or conditions directly resulting from an injury.

For further insight on sequelae, check out this example from the AAPC: “A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela.” One caveat to this example: Don’t fall back on an unspecified code. Instead, ask the patient as many questions as possible to get to the root cause of the original injury.

How do I format a code that requires a seventh character?

As this post explains, “If you add a seventh character to a code with fewer than six characters, you must fill each empty slot with a placeholder ‘X.’” For example:

  1. You choose S44.11, Injury of median nerve at upper arm level, right arm, for your patient.
  2. You look at the instructions for the S44 code category and determine that you must add a seventh character to this code.
  3. Because the patient is receiving routine care for the injury in the healing and recovery phase, you determine that D is the appropriate seventh character.
  4. S44.11 is only five characters long, so you add an X in the sixth position.
  5. You then add your seventh character of D, making the final diagnosis code: S44.11XD, Injury of median nerve at upper arm level, right arm, subsequent encounter.

Do I need to change the seventh character every time a patient returns for another visit?

Nope. You would only change the seventh character if the patient progressed to a different phase of treatment (i.e., the patient moved from the active treatment phase to the recovery/healing phase).

External Cause Codes

Do I have to use external cause codes?

As explained in this blog post, there’s no national requirement mandating any provider—PTs included—to submit external cause codes. However, providers are encouraged to do so when possible. Most of the PT-relevant codes that allow for external cause codes are located in Chapter 19 of the tabular list (which you can access here). Furthermore, some state and regional payers may require the use of external cause codes, so check with each one individually.

What are external cause codes? And how do I use them?

Found in Chapter 20, external cause codes help give context to a particular diagnosis code, and contrary to the name, external cause codes can indicate more than cause. To appropriately apply accurate external cause codes, you’ll also have to consider the place of occurrence, activity, etc. We recommend asking yourself the following questions regarding the patient’s injury: How did the injury or condition happen? Where did it happen? What was the patient doing when it happened? Was it intentional or unintentional?

When do I use external cause codes?

If it’s possible to submit external cause codes for a particular category or section of codes, you will see instructions to do so within the tabular list. Also, bear in mind that you can never submit an external cause code by itself; it always must have a corresponding principal diagnosis code. Here’s a quick clip to show you how to use external cause codes.

What if I don’t know what caused a patient’s injury or condition?

External cause codes are not mandatory (at least not nationally). Remember: you cannot code for what you don’t know. So, if you don’t know the details necessary to select external cause codes—like what caused the onset of the injury, the activity the patient was engaged in at the time of the injury, or where the patient was when the injury occurred—then don’t submit any such codes.

The Great Switch

Should I start using ICD-10 codes now?

Short answer: No.

Long answer: Nooooooooooooo.

Payers will deny claims that contain ICD-10 codes prior to October 1, just like they’ll deny claims that contain ICD-9 codes after September 30.

What do I do about patients with visits spanning the transition date?

We’ve written an entire blog post on what to do prior to September 30 and after October 1, including specific to-dos for that 48-hour transition window. You can check it out here.

Do I need to complete a progress note, evaluation, or re-evaluation to switch to ICD-10 codes?

No. Instead, when it comes time to add ICD-10 codes for the patients who previously had ICD-9, you’ll simply update the diagnoses in the patients’ charts as they come in for appointments on or after October 1.

Will I need to mass-update my patient notes come October 1?

No, there’s no need for a sweeping code change for all your patient notes. You’ll simply update codes within patients’ charts as they come in for their visits.

What about the ICD-10 grace period?

There’s a lot of confusion regarding CMS’s “grace period.” According to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” That means ICD-10 absolutely is happening on October 1. You’ll still receive denials from your commercial payers if you code inaccurately. And, for Medicare claims, you still have to code using valid codes from the accurate code family. For all of the details on what this grace period means for providers, check out this blog post.

The Resources

Where can I get an ICD-10 code book?

You can access the entire code set free of charge here. However, you may find a PT-specific ICD-10 code book useful for educational purposes, as it likely will provide guidance around coding strategy and processes. You can purchase it here.

Where can I find the tabular list?

You can download the tabular list here.

Is there an ICD-10 cheat sheet for physical therapists?

We have a wealth of educational resources that you can download here. However, we wouldn’t recommend using a “cheat sheet.” As most providers know, certain CPT codes are only payable when used in conjunction with certain ICD-9 codes. Thus, you may be tempted to quickly crosswalk those ICD-9 codes and tack up a new reimbursement cheat sheet—or worse, download the first cheat sheet you find online. Don’t. The rules aren’t the same, and crosswalks typically yield unspecified ICD-10 equivalents. As this ICD-10 for PT article explains, “One of the main battle cries of the new code set is increased specificity, and the transition to ICD-10 represents a giant step away from the use of unspecified codes (unless one of those codes truly represents the most accurate description of a patient’s condition). Thus, if you submit an unspecified code when a more specific code is, in fact, available, you could put yourself at risk for claim denial.”

Do you have any ICD-10 information specific to hand therapy?

We recommend checking out this ASHT page.

Do you have any ICD-10 information specific to pelvic health?

We recommend checking out this resource.

Claims, Claims, Claims

How do I handle billing for services provided before and after October 1?

We recommend that practitioners finalize notes and get claims submitted for all dates of service prior to September 30 before October 1 hits. That way, you’re able to start with as clean of a slate as possible come October 1. For additional info on dual coding, check out this post.

Are the 1500 forms going to change? How many ICD-10 codes will be allowed on the 1500 form, and how should I order them?

HCFA 1500 forms were updated in 2013 to accommodate ICD-10, so you shouldn’t have any problems there. You can list up to 12 ICD-10 codes. Keep in mind, though, that only the first four can be linked to CPT codes. Thus, it’s imperative that you arrange the ICD-10 codes in order of importance, with the codes that best justify the medical necessity of your services appearing at the top.

How will ICD-10 affect CPT codes (e.g., 97001, 97110, and 97140)?

ICD-10 does have a set of procedure codes, but anyone who currently uses CPT codes to designate procedures will continue to do so. So, if you’re using CPT codes, ICD-10 will not change that. You can continue using CPT codes as you do now, even after October 1.

Compliance

How does ICD-10 work with therapy cap exception codes?

There haven’t been therapy cap exceptions for a while now. In 2014, Medicare introduced a two-tier exceptions process. In the first tier, which is the Automatic Exceptions tier, therapists affix the KX modifier to necessary services provided above the cap amount. To learn more about the therapy cap, check out this guide.

How does ICD-10 affect the KX modifier?

It doesn’t. You will continue using the KX modifier to denote automatic exceptions in the same way you currently use this modifier.

Will ICD-10 affect G-codes?

ICD-10 will not affect functional limitation reporting (a.k.a. G-code reporting). The current rules will still apply after October 1.

Documentation

How do I handle direct access patients in ICD-10?

We’ve received tons of questions about how to choose the most accurate diagnosis codes for non-referral patients. For advice at every stage of the entire code selection process, check out this blog post.

Keep in mind, though, that this advice isn’t purely for direct access patients. Just because you receive a diagnosis code from a referring provider doesn’t mean you can accept that code blindly, plug it into your documentation and your claim forms, and expect to get paid. You should use the physician diagnosis to inform you on the patient’s situation, but then use your own clinical judgment and skills as a medical professional to diagnose the patient based on what you’re actually going to treat. To learn more about selecting diagnosis codes that help justify treatment, check out this blog post.

What’s the difference between medical diagnosis and treatment diagnosis?

The treatment diagnosis is the one that represents the injury or condition that you, as the therapist, are treating. The medical diagnosis is typically the one that comes with a referral patient’s script. Usually, the treatment and medical diagnoses match. If they don’t, it’s a good idea to get the physician to sign off on the treatment diagnosis before you bill.

Are there V codes in ICD-10?

ICD-9’s V codes will become Z codes in ICD-10, but as explained in this blog post, “A simple mapping of the V57 series of codes found in ICD-9-CM over to ICD-10-CM is not possible, as codes that duplicate the V57 series currently are not included in ICD-10-CM classification.” Furthermore, because V57.1 does not provide specific, detailed information about the patient’s diagnosis—and thus, does not justify the medical necessity of the treatment—using a similar code in ICD-10 could lead to claim denials. Instead, you should select whatever code explains the patient’s diagnosis in the most specific way possible. For more on the importance of coding for medical necessity, check out this blog post.

How do I code for surgical aftercare?

As explained in this resource, the aftercare Z codes should not be used for aftercare of injuries/fractures where seventh characters are provided to identify subsequent care. That said, you won’t always be providing aftercare for injuries—especially in cases involving surgical aftercare. For that reason, ICD-10 contains a few options for coding for surgical aftercare. A couple examples: Z51.89, Encounter for other specified aftercare, and Z47.1, Aftercare following joint replacement surgery. Please note that when you use aftercare codes, you also should code for any underlying conditions/effects. Codes for bone, muscle, and joint conditions that are chronic or recurrent—or that result from a healed injury—are typically found in chapter 13. Also, if you’re coding for joint replacement aftercare, you should include a code indicating which joint was replaced (e.g., V43.65, Joint replaced, knee).

What if I don’t have enough information to select a more specific code?

Select the most specific code you can based on the information you have. In some cases, you may need to contact a referring provider for additional information. But if you’ve exhausted all options and still can’t obtain the information necessary to select a more specific code, just make sure you clearly document the reasons behind your code selection within your documentation.

What if a more specific ICD-10 code does not exist?

ICD-10 requires you to code as specifically as possible, but there may be instances in which codes for your specific diagnosis do not exist, and you’ll have to use an unspecified or generalized code. You can’t code for what you don’t know; just make sure you communicate all the details in your documentation. To learn more about when to use unspecified codes, check out this blog post.

Do I remove codes as my patient improves?

If the patient’s primary diagnosis changes, and you need to update the plan of care, then you should update the diagnosis code. However, if the patient is simply making progress, you can document his or her progress as normal.

How many ICD-10 codes do I have to add for each patient?

There is no minimum or maximum number of codes you can record (though not all will necessarily flow through to your billing, and obviously, you will need to enter at least one). Just make sure you order the diagnosis codes you do submit in order of importance, with the primary diagnosis at the top.

Can’t I just use the ICD-10 code I receive from the referring physician?

Because clinical judgment is such a crucial part of selecting the appropriate diagnosis code, the therapist may need to get involved with code selection to ensure that:

  1. The selected code is the most specific one available to describe the patient’s condition, and
  2. The code justifies the medical necessity of the services provided.

In some cases, the codes sent by referring physicians may meet that criteria, but ultimately, it’s your clinic’s responsibility to code correctly. After all, it’s your clinic—not the physician’s—that will end up suffering the consequences for inaccurate coding. Don’t just take the physician’s word as gospel. Your physicians don’t have the depth of neuromuscular knowledge and expertise that you do. You are best equipped to make the most specific diagnosis possible, and that is exactly what ICD-10 requires.

How do I code for multiple body parts?

For single conditions involving multiple sites, such as osteoarthritis, there often is a “multiple sites” code available. If no “multiple sites” code is available, you should report multiple codes to indicate all of the different sites involved. For a patient seeking treatment for multiple conditions involving multiple body parts, you would create separate cases just as you do with ICD-9.

If a patient is experiencing the same condition on both sides (i.e., right and left), how do I code for that? I noticed some ICD-10 codes don’t have “bilateral” options.

In some categories and families of codes, there is no “bilateral” option for denoting laterality. In those cases, you would need to submit separate codes for both the left and the right sides. This is for data-tracking purposes (e.g., tracking the total number of “left” and total number of “right”).

If a patient has multiple diagnosis codes, which one should be the primary diagnosis?

Your primary diagnosis code should be the one that most closely aligns with the reason the patient is seeking your services. From there, you should order the codes according to importance and significance regarding medical necessity.

Whew! That was a lot of information, right? Hopefully, it helped ease your mind. But remember these are the answers to only your most burning questions. Need more ICD-10 advice? We’ve got your back. Check out these posts—and tons more—on the WebPT Blog:


ICD-10 Coding Practice for OTs: Down Syndrome

August 31st, 2015
ICD-10, ICD-10 Example, Preparation, Transition

Are you an ICD-10 coding expert? Do you feel prepared to take on the complexities that are an inevitable—yet, crucial—component of the new code set? No? Well, not to worry. ICD-10 is certainly complex, and you should take this transition seriously. Still, you shouldn’t let fear (and frustration) get the best of you. With that in mind, what can you do to make the transition smoother? Practice, practice, and well, more practice. Speaking of practice, here’s an occupational therapy coding example from compliance expert Rick Gawenda. Walking through this example should help you fine-tune your coding skills. Here’s the situation:

The Patient

The patient is a 7-year-old female with Down syndrome (meiotic). Her parents have been referred to occupational therapy, because she’s having problems with her posture and walking. She appears to be suffering from muscle weakness. How would you code for this?

The Codes

Primary Code

  • Q90.0, Down syndrome. More specifically, this code indicates the patient’s diagnosis of Trisomy 21, nonmosaicism (meiotic nondisjunction).

Additional Codes

With ICD-10, you should indicate the reason for outpatient therapy whenever possible. In this case, you would use the following codes:

  • R26.2 for the difficulty walking or R26.89 for other abnormalities of gait and mobility
  • M62.81 for generalized muscle weakness
  • R29.3 for abnormal posture

The Description Synonyms

You’ll have to use your clinical judgement to determine whether you’d code R26.2 (difficulty walking) or R26.89 (other abnormalities of gait and mobility). During your evaluation, you likely will find that one code is more appropriate than the other. One way to determine which code you should select: review each code’s description synonyms. Here are the description synonyms in this situation:

Difficulty walking. The description synonyms for R26.2 are:

  • Difficulty walking
  • Walking disability

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

The Summary

When all’s said and done, coding to the highest level of specificity requires you to change your mindset. When you account for additional information pertaining to each patient’s condition, you’re able to determine which codes accurately explain the scenario. Feeling better about the transition after reviewing this example? Want to see more examples like this one? Watch WebPT’s free ICD-10 bootcamp webinar. In it, we provide step-by-step guidance on how to code for this example—and ones that are even more complex. With our help, you’ll be ready well before October 1.


ICD-10 from the Patient’s Perspective

August 19th, 2015
ICD-10, Patient care, Transition

We know you’re working hard to get your clinic ready for ICD-10. From the front office to the back, every person in your practice is gearing up for October 1, 2015—except for your patients. But that’s not a bad thing. In fact, in most cases, your patients don’t even need to know about ICD-10. Have you ever explained ICD-9 codes to a patient? Probably not—and your patients have likely never asked about them, either. So why would that change along with the healthcare industry’s code set?

Hint: It wouldn’t.

Patients won’t suddenly develop the urge to learn about medical billing just because you’re switching to ICD-10. The majority of your patients are much more concerned with getting better than they are about the codes you’re using to bill their insurances. Besides, informing patients of ICD-10’s demand for greater documentation specificity might cause them to unnecessarily question your pre-ICD-10 documentation practices.

Ultimately, when it comes to switching code sets, what your patients don’t know won’t hurt them—unless you expect your clinic’s productivity to take a deep dive, especially with respect to the speed of patient intake. Even in that situation, you don’t need to spend 30 minutes explaining (or complaining about) the transition to ICD-10. Instead, simply tell patients that, due to new government regulations, your staff must complete additional paperwork, which has caused some temporary front office delays. Any patient who’s had to file taxes will cut you some slack.

Luckily, you’ve got one less thing to worry about when it comes to preparing your practice for ICD-10. To put all of your coding concerns to rest, don’t miss our upcoming ICD-10 Bootcamp webinar on August 31, 2015. Register here to save your spot.  


ICD-10 Talk with Dr. Heidi Jannenga: What is ICD-10?

August 19th, 2015
ICD-10, ICD-9, Preparation, Transition

As you’re probably—hopefully—well aware, the transition to ICD-10 is happening in about six weeks. And this is no tiny tweak; on October 1, 2015, all HIPAA-covered healthcare providers in the entire US must begin coding patient diagnoses using codes from the new ICD-10 code set. To help rehab therapists take on this change confidently—and emerge from ICD-Day unscathed—we’ve provided tons of free ICD-10 educational materials, from blog posts and guides to interactive games and webinars. And now, we’re upping the ante with video: introducing ICD-10 Talk with Dr. Heidi Jannenga.

In the first video of this new series, Heidi provides a brief explanation of ICD-10 and how it differs from ICD-9. Stay tuned for more awesome ICD-10 Talk videos, and be sure to check out the rest of the resources available here on ICD10forPT.com. Have a question? Submit it using the question form at the bottom of this page, and we’ll round up an answer for you.


The Penny-Pincher’s ICD-10 Plan

July 24th, 2015
ICD-10, ICD-9, Preparation, Transition

With only about two months to go until the mandatory switch to ICD-10, your clinic should be fully entrenched in its preparations. If you started early, you’re probably feeling pretty good about where you’re at. Maybe you even feel totally ready to tackle the change. But if you didn’t start early—or if you haven’t started at all—you’re likely feeling the pressure on your practice and your bottom line. If your clinic’s staff doesn’t understand how to correctly code using ICD-10, you’ll suffer the financial consequences. Luckily, the Centers for Medicare and Medicaid Services (CMS) have granted providers with a one-year grace period—which could save you some delayed payments and claim denials due to ICD-10 coding errors. But the cost of transitioning to ICD-10 begins well before we actually switch code sets.

To help cover the cost of preparation, you could consider securing a line of credit with your bank or having three to six-months’ worth of cash on hand to keep your clinic afloat. But if those options aren’t available to you—or if you’d rather keep your purse strings tied up—you’ll need a penny-pinching preparation plan. Here are seven tips to help you prepare for the switch to ICD-10 without breaking the bank:

  1. Clear out your current reimbursement backlog and collections accounts to beef up your cash reserves.
  2. Take advantage of free educational tools, like ICD-10 for PT and the WebPT Blog, to educate you and your staff. Training is necessary, but it doesn’t have to be expensive.
  3. Determine your practice’s most commonly used diagnosis codes—and their most specific ICD-10 equivalents—to soften the blow to your productivity come October 1.
  4. Test with your payers and vendors. Testing externally is free and verifies that all of your software and outsourced services are ready to receive, process, and remit for ICD-10 codes. If they aren’t ready, you might have to consider working with new vendors. That might not be in your budget, but unprepared vendors will cost you more in the long run.
  5. Asses your current billing workflow. Determine how quickly and cleanly your practice currently processes and receives payment for claims using ICD-9 codes. This will allow you to correct any kinks in your workflow, and you’ll have a much better sense of how ICD-10 affects your cash flow after the transition.
  6. Test internally. Ensuring your team efficiently and appropriately assigns ICD-10 codes doesn’t cost you much more than time right now, and it will save you a lot of money later.
  7. Create a retention plan. If any of your staff are already trained on ICD-10, they’re a valuable commodity. Do what you can to keep these employees—and their knowledge—at your practice.

Ready or not, we’ll have to transition to ICD-10 on October 1 (barring any unlikely Congressional delays). Fortunately, it doesn’t have to cost an arm and a leg to prepare your practice. With these seven tips in mind, you can get your clinic up to speed—and keep your savings intact.


Here’s What You Need to Know About the AMA and CMS Announcement

July 14th, 2015
ICD-10, ICD-10 Delay, Preparation, Transition

“Extra! Extra! Read all about it!” When it comes to the Centers for Medicare & Medicaid Services (CMS), there’s no shortage of “extra” announcements in the news these days. And even though it’s not in print, ICD-10 news is especially important right now, as implementation is slated to take effect in just a few short months. If you’ve been following our blog, you’ve seen us cover everything you need to do before October 1 to prepare your clinic, but mistakes happen. That’s why CMS—with a push from the American Medical Association (AMA)—made a move that could help soften the blow of the transition. So, even if your preparedness doesn’t quite fit the bill (literally), you still have a chance of receiving payment come October 1. Here are the details of the recent announcement:

Flexible Review

CMS and the AMA want physicians and other practitioners (therapists included) to make a successful transition to ICD-10. So, they recently announced a 12-month period during which, according to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” So, what does that mean?

Are providers off the hook for coding mistakes on Medicare claims?

The short answer is “no,” because:

However, if your claim doesn’t contain any errors other than those related to code specificity—and you’ve used a valid code from the correct family of codes—Medicare won’t deny your claim within that 12-month period.

How does this decision affect Medicare quality reporting?

CMS won’t apply accuracy penalties for programs like Physician Quality Reporting System (PQRS) as long as the eligible provider “submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes),” says CMS.

ICD-10 Ombudsman

The ICD-10 Ombud—what? According to my handy-dandy online dictionary, an ombudsman is “a person (such as a government official or an employee) who investigates complaints and tries to deal with problems fairly.” And as part of this announcement, CMS described its plans to designate an ICD-10 ombudsman to investigate and help providers with their ICD-10 troubles during the transition. CMS hasn’t released many details about this resource other than the fact that the ombudsman will work closely with regional Medicare offices to better assist providers. As October 1 approaches, CMS will release more details on how you can contact the ombudsman for ICD-10 assistance.

Advanced Payment

What happens when there are system, administrative, or ICD-10 implementation problems with Medicare contractors? A conditional partial payment might be available. However, providers must repay any advanced payment, and they’re only eligible to receive such payments if they meet certain conditions.

What are the conditions?

CMS describes them in 42 CFR Section 421.214. Essentially, to receive advanced payment, Medicare suppliers can apply through their applicable Medicare Administrative Contractor (MAC).

 

Ultimately, CMS will review its flexible, 12-month timeline and adjust it based on the success of ICD-10 adoption. And don’t forget: Just because providers have some wiggle room when it comes to coding for complexity, it doesn’t mean they’re totally off the hook. The ultimate goal is to submit the most complete and accurate code—the first time, every time.