5 Reasons ICD-10 is Getting a Lot Tougher in The Future

By Michael Carroll on October 18, 2016

If you recall CMS’ statement from this past August, ICD-10 is getting a lot tougher since October 1st. For the first 12 months after CMS opened ICD-10 coding, Medicare promised not to deny physician or practitioner claims for reimbursement submitted under the fee-for-service Part B physician fee schedule and based solely on the ICD-10 diagnostic codes so long as the code is a valid code and from within the right family of codes (the family meaning the first three digits of the code that define the category). Well, the 12-month grace period is up so we put together five reasons why complying with ICD-10 coding is tougher now.

  • Coding Flexibility Ends. On and after October 1, 2016, health care practitioners must code health care encounters to the “highest degree of specificity” (in CMS’ words) that corresponds to the clinical documentation and clinical knowledge for the patient. Unspecified codes remain the best choice when they accurately reflect the clinical experience for a particular patient. With over 75,000 diagnostic codes in ICD-10 (an increase seven-fold over the 11,000 codes in ICD-9), CMS claims reviewers will hold medical care coders to the standard of excellence that requires the highest degree of specificity.
  • Coding for Diabetes has the most changes under IDC-10. Prior to IDC-10, physicians used terms like “controlled”, “uncontrolled”, or “juvenile onset” to describe the types of Diabetes Mellitus. Those terms, however, are now obsolete according to the American Academy of Ophthalmic Executives. The proper terms under IDC-10 is Type 1 Diabetes (lack of insulin produced by the body) and Type 2 Diabetes (the insulin resistant variety). When Insulin is part of the treatment plan then the coder will add this separately as code Z79.4. For all practical purposes, then, only an endocrinologist may have the knowledge on how to code the type of Diabetes cases now.
  • Diabetes cases now have one code, instead of multiple codes. For instance, Type I Diabetes without complications codes as E10.9. Diabetes Mellitus with complications requires using the codes designated under the “with” sublist and that, in turn, generates one code. For example, Type I Diabetes Mellitus with severe nonproliferative diabetic retinopathy but without macular edema generates a code E10.349. A Type 2 Diabetes Mellitus with mild nonproliferative diabetic retinopathy with macular edema gets a code E11.321. Coders must use extra care when selecting a diagnosis code if they are going to accurately reflect the diagnosis. The American Academy of Ophthalmic Executives provides a Diabetes Physician Decision Tree to help coders make the right choice.
  • Diabetes Mellitus and associated conditions. As an example of the new coding in effect on and after October 1, 2016, Diabetes Mellitus has 53 subsets under the associated “with” listings. The ICD-10-CM Official Guidelines for Coding and Reporting says that CMS will interpret the “with” designation to mean “associated with” a particular disease or “due to”‘ the particular disease. A recent clarification in March 2016 says that CMS interprets the term “with” to mean there is a link between Diabetes and the conditions that follow in the list. For example, ICD-10 shows that gangrene, neuropathy, and amyotrophy link to Diabetes. In the case of Diabetes Mellitus, the physician does not need to make the case for a link to the appropriate condition in his diagnosis because the coding includes the idea that certain conditions have a cause-and-effect relationship to the disease. You will see under Code E11.9 for Diabetes Mellitus there follows quite a sublist of conditions associated with the disease — all with their own code designations. This may confuse coders since it is different from the way coding happened in IDC-9-CM for coding under Diabetes. If a physician’s notes say that a specific condition is not a result of Diabetes Mellitus, then the coder should not use the “with” code associated with Diabetes. This means, in practical terms, that the coders must review the entire documentation record to accurately select codes that represent the clinical health interview. If after a review, it is not clear whether two conditions link together, coders should post the question to the provider. You can review examples of situations in which coders needed to query the provider in the February 2013 issue of the Journal of AHIMA.
  • Not all IDC-10 codes include laterality. “Laterality” is unique to ICD-10 and just 36% of all ICD-10 codes include laterality. Laterality means to distinguish between the left and the right. It is important for physicians to note in the health documentation whether right versus left and proximal versus distal are part of the diagnosis. If the physician does not document the laterality of the condition, the coder may not choose the code that specifies the condition to the highest degree as required by ICD-10. There are still unspecified codes but those would not apply to a condition that has a laterality code in the ICD-10 list. For example, in the ER, the following conditions are common: right upper quadrant pain; left upper quadrant pain; right lower quadrant abdominal pain; left lower quadrant abdominal pain. As you can tell from these limited examples, it is important to specify the laterality of the patient’s condition in order for a coder to code with specificity.

To learn more about ICD-10-CM’s coding, CMS provides an online slide-show with the basics that you might find interesting.

To talk more about this topic, or anything else, please contact us. We look forward to helping you with your billing and coding needs so you and your staff can get back to the practice of medicine.