ICD10 CM/PCS and Pre-Existing Conditions

By Julia Croly, CPC, CPC-P

With ICD-10-CM/PCS on the horizon, health plans will need to review their policies and procedures that work behind the scenes to administer benefits and adjudicate claims.  Does your health plan deny claims for pre-existing conditions?  Who in your health plan is responsible for the maintenance of the pre-existing list of conditions and their ICD-9-CM code(s)?

Let’s step back and look at what “pre-existing” is and what it means to members and health plans.

A pre-existing condition is a medical condition that existed prior to the date the member enrolls with a health insurance company. Most insurance companies use one of two definitions to identify such conditions. Under the “objective standard” definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, “prudent person” definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.
Once enrolled a claim may be denied for pre-existing conditions.

What are some of the most common pre-existing conditions? They include AIDS, psychiatric disorders, asthma, psoriasis, diabetes, osteoarthritis, cancer, fibromyalgia, high blood pressure and heart disease. The new kid on the block to make the pre-existing list is obesity.

As a coder, you know where these codes are in ICD-9-CM but what about when we go to ICD-10-CM?  Just as with ICD-9-CM some pre-existing conditions are single codes while others may be complete chapters. The following table will begin to familiarize you with those common pre-existing conditions and their ICD-10-CM location.

PRE-EXISTING CONDITION

ICD-10-CM LOCATION

AIDS

Chapter 1: Infectious Diseases   B20

Psychiatric Disorders

Chapter 5: Mental and Behavioral Disorders F01-F99

Asthma

Chapter 10: Diseases of the Respiratory System J45.20 – J45.998

Psoriasis

Chapter 12: Diseases of the Skin L40.0 L40.9

Diabetes

Chapter 4: Endocrine, Nutritional and Metabolic Diseases E08.00- E13.9

Osteoarthritis

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue M15.0- M19.93

Cancer

Chapter 2: Neoplasm’s C00.0-D48.9

Fibromyalgia

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue M79.7

Hypertension and heart disease

Chapter 9: Diseases of the Circulatory System I10.0 – I79.8

Obesity

Chapter 4: Endocrine, Nutritional and Metabolic Diseases E69.01-E66.9


Health plans will have to change the diagnosis codes in their pre-existing tables to be compliant with ICD-10-CM. As a certified coder in a health plan you may be asked to consult in this effort. We will all have to learn ICD –10-CM. With time you will become very familiar with these new codes, as you are with ICD-9-CM. Just remember that at one point in your coding career, ICD-9-CM seemed foreign to you too. With time and a little effort on your part, you can make a smooth transition.

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5 Responses to “ICD10 CM/PCS and Pre-Existing Conditions”

  1. Bernice B. King says:

    This information is wonderful. I am considering taking a course in Medical Coder/Biller – ATD/Comprehensive Cert. Prog. very soon.

    Do you have monthly news letters available?

  2. D Fagan says:

    I am currently enrolled in a Medical Coding/Billing Specialist diploma program and would also like to know if you have a monthly/quarterly newsletter that I can subscribe to.

  3. Bonnie says:

    I do the billing for hearing aids and audiometric, impedance, and balance testing to Medicare/Medicaid and other insurance companies. And my question is when a PCP or ENT refers a patient for audiometric, impedance, balance test (Vertigo) or for a hearing aid to assist the patient with hearing loss will we need to use a modifier for testing or for the hearing aids?

  4. dawn says:

    I have a question: The insurance Co. (Anthem) is doing a pre-x investigation on a 4year old for dx codes 786.2 a cough 780.60 a fever. We billed a new pt code 99203- which, in my mind is telling the insurance this is a new patient being seen for these dx codes. Basically the pt came in with a cough an fever (hence) Flu Season. I udnerstand when the insurance does pre-x reviews on pre-x conditions but this is for a 4 year old pt being seen for flu/cold symptoms. are these common dx codes for pre-x and why?

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