Are YOU Ready?

On October 1, the Centers for Medicare and Medicaid Services (CMS) lifted its partial code freeze and thousands of new codes went into effect. In addition, the Medicare grace period on code specificity for Part B post-payments audits also ended.

According to CMS, the ICD-10 flexibilities “were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.” These flexibilities are not extended beyond October 1, and CMS plans no other guidance around the topic.

What does that mean for your coding efforts?

For most organizations, the biggest adjustment will be avoiding unspecified ICD-10 codes when documentation supports a more detailed code. CMS is not phasing in specificity requirements, as it believes providers should already be coding to that level. Historically, insurance companies do not outwardly specify which codes they will and will not reimburse. This is because insurers want providers to submit claims based on the accuracy of a patient’s condition, not based on which codes get paid.

The Centers for Disease Control and Prevention (CDC), which administers the diagnosis codes, released the 2017 ICD-10-CM codes on June 24, 2016. This information can be found at www.cms.gov. There are 1,974 additions, 311 deletions, and 425 revisions. The resulting total for diagnosis codes is 71,486.

The addenda for the Index, Table of Drugs and Chemicals, Neoplasm Table, External Cause Index, and Tabular are included in this release. The addenda provide information regarding the changes for the code set.

The Code Descriptor in Tabular Order provides the code descriptor at each level of the code set. Of special interest, the 2017 ICD-10-CM Official Coding and Reporting Guidelines contains a new coding convention #19 in regards to Code Assignment and Clinical Criteria. This guidance states “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 physician to establish the diagnosis.”

A brief highlight of some of the additions and changes throughout the code set include:

  • There is only one addition to Chapter 1 (Infectious and Parasitic Diseases) which is A92.5. This code has been assigned by the World Health Organization (WHO) for the Zika Virus.
  • The changes in Chapter 5 (Mental, Behavioral, and Neurodevelopmental Disorders) include additions to capture hoarding, various obsessive-compulsive disorders, and social pragmatic communication disorder.
  • Chapter 9 (Diseases of the Circulatory System) updates include the addition of hypertensive urgency, emergency, or crisis; reducing specificity of nontraumatic subarachnoid hemorrhage and the communicating artery; expansion of the cerebral infarction and sequela of stroke codes; addition of aneurysm of precerebral and vertebral arteries; and addition of dissection of unspecified arteries.
  • Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue) added bunion, bunionette, pain in joints of the hand, more specificity to temporomandibular joints, cervical disc disorders at specific levels, atypical femoral fractures, and periprosthetic fractures.
  • Chapter 14 (Diseases of the Genitourinary System) have a few title changes as well as the code additions for specific urinary incontinence conditions, various prostatic dysplasia, testicular and scrotal pain, erectile dysfunction, ovarian cysts, conditions of the fallopian tubes, and complications of the urinary tract including fistulas, hemorrhage, infection, malfunction, et cetera.
  • Chapter 19 (Injuries, Poisoning, and Certain Other Consequences of External Causes) changes include significant number of additions regarding the specific fractures to bones of skull; various fracture types of the foot; title revisions to complications involving prosthetic devices; new stenosis of cardiac stent codes, and additions to complication types including breakdown, displacement, infection, erosion, exposure, pain, fibrosis, thrombosis, and leakage.

After review of the entire list of ICD-10 changes contained in the CDC link above, it becomes increasingly evident that the level of code detail creates an unprecedented opportunity to improve documentation accuracy and specificity, which will ultimately help drive better patient outcomes.

Dean Dorton can help by offering comprehensive coding chart audits and physician education training. For more information, contact Dawn Wilson at 502-566-1007 or dwilson@ddafhealthcare.com.