ICD-10 Leniency Ends While MACRA Advances
ICD-10 presents a double-punch of changes while reporting standards are tightened. Entering its second year, it includes thousands of new codes implemented October 1, 2016. For example, the new ICD-10-CM diagnosis code set has:
- 1943 new codes,
- 422 revised codes, and
- 305 deleted codes.
ICD-10-PCS, the Procedural Coding System used by hospitals and facilities is increasing, as well, with:
- 3651 new codes,
- 487 revised codes, and
- 50 deleted codes.
Quality Requires Specificity for CM
The new codes allow even greater specificity to be reported in the patient’s medical record, and also carry an additional documentation burden on providers.
First, Medicare’s “transition flexibility” is ending. This leniency previously allowed a diagnosis code within the same “family” to be submitted on a claim in which only a related code was represented in the medical documentation. CMS contractors were not allowed to deny payment during a retroactive review for claims fitting this category through September 30, 2016. Now that this time frame has passed, expect all carriers to begin combing through claims for adherence to ICD coding guidelines and levels of specificity.
The Quality Payment Program, implemented by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will implement two new programs in 2017 that will affect 2019 reimbursements. The quality of data in physicians’ claims will need to accurately reflect both the patient’s encounter and diagnoses on the date of service.
For example, there is a large increase in diabetes codes with ophthalmic complications. These codes now indicate laterality (which eye or eyes have the stated disease). New concepts include staging of retinopathy and more detailed coding for retinal detachments.
In gastroenterology, there is now inclusion of stromal tumors and additional types of colitis and gastroenteritis. Codes for pancreatitis have increased, and there is now a code for gluten sensitivity.
Codes identifying complications of procedures have also increased. Hemorrhages, hematomas, and seromas following a procedure can now be identified with greater accuracy, and mechanical complications are likewise identified in greater detail.
Orthopedics has a large overhaul, with hundreds of new injury codes that include fractures of the femur and skull base. Other conditions include cervical disc diseases and temporomandibular joint disorders.
Obstetrics and gynecology codes have increased to include laterality for many ovarian disorders and additional pregnancy and delivery complication codes.
And, as always, there are new external cause codes, identifying different environments and circumstances in which a patient experienced an injury. At times, these codes appear to bring a sense of humor to the ICD-10 library. Take for example last year’s W61.33XA Pecked by chicken initial encounter.” Physicians and coders can be grateful if they never need to utilize this code.
PCS Also Changing Dramatically
The large volume of codes is to some extent due to the partial code set freeze that had been in place for the past four years while ICD-10 implementation was delayed. Additional updates can be expected each year as the specificity and numbers of disease processes as well as medical procedures continue to grow.
Many of the code changes are concentrated in different specialties. Cardiology procedure coding accounts for 97 percent of the PCS codes as well as some of the new diagnosis codes. New diagnosis concepts identify the cause of cerebral infarctions, hypertensive urgency, and deficits following cardiovascular incidents.