There Is a Bright Side to ICD-10-CM
Counteract the negative hype of ICD-10-CM with well-informed benefits.
Many people focus on the differences between ICD-9-CM and ICD-10-CM, and the problems that implementing a new diagnosis code set may cause. I prefer to focus on the positive aspects of moving to ICD-10-CM.
Providers Benefit in Many Ways
The best thing about ICD-10-CM is that it allows you to code to a higher level of specificity. The more precise the documentation, the more exactly you can code. This puts pressure on providers to make sure their documentation is up to snuff. And that is a really good thing.
Decreased Denials – More specific documentation will improve medical decision-making. The medical decision will be supported by a clear picture of the encounter with the patient. This will help to reduce denials, and will save time and money for the payer, provider, and patient.
For example, think about what happens when there is a denial for medical necessity. It takes time and money to process a denied claim. The claim needs to be reviewed to determine why it was denied. The documentation needs to be reviewed to see if it supports the codes that were selected. Then, the documentation needs to be sent in with the claim. Phone calls to the payer may be necessary, and the patient may call you with questions regarding the denial.
When documentation paints a clear picture and services are coded to the utmost specificity, claims are less likely to be denied, and providers are more likely to be reimbursed in an appropriate, timely manner.
Consolidation through Combination Codes – ICD-10-CM has many combination codes. A combination code is a single code used to classify two diagnoses: a diagnosis with an associated sign or symptom, or a diagnosis with an associated complication. Assigning a combination code reduces the time it takes to find and apply multiple codes.
For example, when coding for pressure ulcers in ICD-9-CM, two codes are required: one for the ulcer and one for the stage. In ICD-10-CM, we have one combination code that includes the site of the ulcer and the stage.
Severity Shows Necessity – In ICD-9-CM, the codes for otitis media do not have an option for recurrent. ICD-10-CM has codes for acute, chronic, and recurrent, in addition to type and laterality. Using the recurrent code helps to show medical necessity, which assists in getting approval for surgery.
External Cause for Efficiency – External cause codes enable the payer to receive specific information regarding the injury. This can help the payer determine quickly if it is responsible for paying the service, and mitigate problems between the payer, provider, and patient.
A Big Benefit to Patients
How can ICD-10 benefit a patient? To provide a better understanding of how ICD-10-CM can save time and hassles for patients, let’s look at an example of what happened to Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, vice president of ICD-10 Training and Education at AAPC:
“Keep in mind, I am a seasoned healthcare professional. I know what to expect and how to handle things. When I explain the timeframes, you need to imagine the impact this case would have on an ‘average’ patient.
“While traveling for work several years ago, I slipped and fell in an icy hotel parking lot. I broke both my ankle and wrist. I was out of state, out of network, and needed surgery urgently.
“As I handed over my primary insurance card, I apologized because I knew what was going to happen. At the time of treatment, it was not known who would end up financially responsible. Would it be the hotel, workers’ compensation, or my personal insurance? Because we are sometimes impatient in healthcare and we want our doctors to get paid, everyone billed my personal insurance. Six weeks later, the hotel declared the fall to be an ‘act of God,’ and workers’ compensation accepted responsibility for the claims. By this time, a lot of money had changed hands for services such as emergency room treatment, DME, prescriptions, surgery, and physical therapy, to name a few.
“It took me more than two years to get it completely straightened out. That was after too many phone calls to treating providers, hospital systems, health plans, and others. Remember, I know the industry. As soon as I got the information from my workers’ compensation plan, I personally called everyone.”
The problem? According to Buckholtz:
“My personal insurance paid and no one wanted to rock the boat and do all the work required to go back and fix it. It was not until my personal plan started taking money back that I got action. I was steered toward collections services twice by companies not understanding the problem was no longer a balance billing issue, but a workers’ compensation issue. Two long years of working to correct it not only consumed plenty of my time, but that of countless others, as well. Correcting the situation required many administrative tasks, including rebilling, refunding, researching, appealing, and waiting for resolutions.
“Now, think about this same situation in an ICD-10-CM world. If the provider could’ve used a code to spell out that a patient fell on ice in the parking lot of a hotel while traveling for work, how would’ve that helped? Personal insurance would’ve said, ‘We aren’t responsible for this claim and we aren’t going to pay.’ No money would have changed hands and the claim would’ve been suspended until I provided the workers’ compensation information. Or in the worst/best case scenario, it would have been the patient’s own financial responsibility (thereby making sure the patient gets the information out quickly, lest he or she have to pay). Think about how much time could have been saved by the providers’ offices, the health plans, the pharmacy, the physical therapists, and, of course, the patient.”
Other Benefits to Patients
There are many other examples on how the use of ICD-10 codes can benefit a patient, such as quicker, more efficient approval of services and procedures.
Preventive vs. Sick – The preventive codes in ICD-10-CM include the specificity of “with” and “without” abnormal findings. Preventive services vs. acute visits can be clearly defined with the use of the new preventive codes in ICD-10-CM.
For example, a patient comes in for a well-child checkup. During the exam, the provider discovers the patient has an ear infection, which is addressed. The provider would code the abnormal findings and the otitis media. The provider would also report the preventive medicine service, as well as an evaluation and management (E/M) visit with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Non-compliance Codes – Non-compliance codes have been expanded in ICD-10-CM. The use of the non-compliance codes protects the provider legally by documenting when patients are not taking their medication as prescribed or are non-compliant with their treatment. Reporting non-compliance codes aides in the tracking and trending of how many people do not take their medication correctly, or forgo treatment recommendations, and the reasons why.
For example, there is a code for non-compliance of medication regimen due to financial hardship. If the code is widely used, it will show how many people do not have the money to pay for their prescriptions. This will show a need to decrease the cost of prescriptions, and that more programs are necessary to help patients receive the medications they need.
Being a positive force and seeing the benefits of ICD-10-CM can provide a different perspective than the confusion and the media hype that seem to speak so loudly.
Jackie Stack, BSHA, CPC, CPC-I, CPB, CEMC, CFPC, CIMC, CPEDC, is an ICD-10 specialist at AAPC.