Changes and Challenges with ICD-10 Coming Soon
Written by Editor   
Tuesday, September 06, 2016 03:50 PM

Last year’s ICD-10 transition went smoothly and with very few hiccups, but healthcare organizations do not have the luxury of resting on their laurels. October 1 marks the one-year anniversary of the code switchover, which brings new challenges they must overcome.

Organizations must now focus on three significant changes that will come into play starting Oct. 1, 2016:

  • The ICD-10 Coordination and Maintenance Committee has lifted the partial code freeze and thousands of new codes have been added for federal Fiscal Year 2017, which begins October 1.

  • The Medicare grace period on code specificity for Part B post payment audits will end Oct. 1, 2016.

  • Payers may begin to adjust medical policies based on the new specificity offered by ICD-10.

The Centers for Medicare and Medicaid Services reports that there are 71,486 diagnosis and 75,789 procedure codes for FY 2017. These include 1,974 additions, 311 deletions, and 425 revisions for ICD-10-CM.

Organizations need to make sure that applicable codes are incorporated into internal applications and processes, while verifying that vendor products support the new codes. Prior leniency in specificity of codes will be going away October 1, with the new mandate that goes into effect. 

In the past, CMS reimbursed incorrectly coded claims under the Part B physician fee schedule—provided that the incorrect code was from the right ICD-10 code family—but no longer.  It used to be if you got close to the right general category of the codes, they wouldn’t penalize you in an audit. That’s ending.

To be in compliance organizations need to ensure that clinical documentation contains sufficient detail to code at the required level of specificity that CMS will soon demand.  On Aug. 18 the CMS addressed the issue of code specificity:  “As of Oct. 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.” 

CMS also states: “Beginning Oct. 1, 2016, all CMS review contractors are able to use coding specificity as the reason for an audit for a denial of a reviewed claim to the same extent that they did prior to Oct. 1, 2015. Review contractors will notify providers of coding issues they identify during review and of steps needed to correct those issues to the same extent that they did prior to Oct. 1, 2015.”

Most the material in the recently released ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 pertain to medical conditions that will be of little use to most of the chiropractic facilities in Texas, but each office will want to review the updated guidelines.  

Several quotes worth highlighting include:

  • The US Federal Government’s Department of health and Human Services provide the following guidelines for coding and reporting using the [ICD-10].  These guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS [National Center for Health Statistics] website.

  • The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings.

  • Adherence to these guidellines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).

  • The importance of consistent, complete documentation in the medical record cannot be overemphasized….  The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

  • The term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.

  • An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other.

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.  For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.  Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code.  These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

  • The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.

  • The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

  • When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.

  • Use of symptom codes

Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

  • Use of a symptom code with a definitive diagnosis code

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.Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

  • Combination codes that include symptoms

ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.

  • The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.

  • The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in conjunction with acute stroke codes (I63) to identify the patient's neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s). At a minimum, report the initial score documented.

  • 7th character “A”, initial encounter is used for each encounter where the patient is receiving active treatment for the condition.

  • 7th character “D” subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

  • 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).

  • 7th character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.

  • Coding of Injuries

When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.

The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.
1) Superficial injuries
Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.
2) Primary injury with damage to nerves/blood vessels
When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.
  • Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

  • A symptom(s) followed by contrasting/comparative diagnoses GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014.

  • Guidelines in Section I, Conventions, general coding guidelines and chapter-specific guidelines, should also be applied for outpatient services and office visits.

These are just a few of the many updates.  These will most directly pertain to the chiropractic profession, but each practitioner is encouraged to check the updated guidelines for themselves to apply the changes to their own circumstances.