Cure ICD-10-CM Miscoding of Preventive Services
A lot rides on you knowing the difference between a preventive service and a diagnostic screening.
Title I, Part A, Subpart II, Section 2713.a.1 of the Affordable Care Act (ACA), signed into law on March 23, 2010, requires commercial insurance plans to cover preventive screening services rated A or B by the U.S. Preventive Services Task Force (USPSTF) with no cost sharing to its plan members. This benefit has been available for over eight years, but incorrect coding — specifically diagnosis coding — persists. Preventive care improves the nation’s health and reduces overall spending by encouraging patients to seek professional medical intervention before costly chronic conditions set in. Our job is to code claims for preventive services appropriately.
Differentiate Between Screening and Diagnostic
When claiming benefits for screening services, you must select and sequence the correct ICD-10 diagnosis codes to ensure the appropriate benefit category is applied for payment with no cost share to the plan member.
To correctly code the diagnosis for these beneficial services, the simple question is: Does the patient have a sign or symptom of the disease? If the answer is “yes,” the service is diagnostic, not screening, and the diagnosis code for the sign or symptom is listed on the claim for that encounter. If the answer is “no,” the service is preventive screening and should be coded, as such. Preventive screenings apply to patients who have no signs or symptoms of the specific disease.
To appropriately assign an ICD-10 code for a screening service, reference the ICD-10-CM Official Guidelines for Coding and Reporting, Section IV, C.21.5, where screening is defined. The guidelines state:
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram). The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
Likewise, the USPSTF states their recommendations for preventive services “apply only to people who have no signs or symptoms of the specific disease or condition under evaluation.”
Sequence Codes Correctly
To determine the primary (first-listed) diagnosis code, again refer to the ICD-10 Official Guidelines for Coding and Reporting, which outlines reporting for outpatient services in Section IV.G of the guidelines. This includes services in hospital-based outpatient settings and provider-based office settings, where many preventive screenings are provided. The guidelines in paragraph G instruct:
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
Unlike inpatient facility coding, where uncertain diagnoses are reported and documented using terminology such as “probable,” “suspected,” “likely,” etc., outpatient coding requires reporting conditions known at the time of the encounter. If a diagnosis has not been established during the encounter, it is appropriate to code for signs and symptoms. If the reason for the encounter is screening, report the screening diagnosis code.
The Centers for Medicare & Medicaid Services (CMS) provides an MLN Matters® educational tool with information about Medicare-covered preventive services, including how to properly furnish various preventive services, proper HCPCS Level II and CPT® procedure coding, ICD-10-CM diagnosis coding, coverage and frequency requirements, and Medicare patient liability. Go to: www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html.
One example of a USPSTF Grade A-rated service is screening pregnant women for syphilis. The diagnosis code can be either a Z34 Encounter for supervision of normal pregnancy series code or an O09 Supervision of high risk pregnancy series code. Other codes that may be applicable:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis
Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
Z11 Encounter for screening for infectious and parasitic disease
Z72.5 High risk sexual behavior
Z20 Contact with and (suspected) exposure to communicable disease
If the pregnant patient has signs or symptoms of syphilis, the service is not screening; the service is billed as diagnostic with the ICD-10 code of the specific signs or symptoms of the disease reported.
Don’t Be Led Astray and Violate the FCA
Because there is no cost-share to members for many of these USPSTF Grades A- and B-rated services (the zero-dollar patient liability is calculated outside of plan copays and deductibles), patients may ask for a diagnostic service to be submitted to their payer as a screening. Follow correct coding guidelines and develop a firm written policy to address requests that put your provider at risk for healthcare fraud under the False Claims Act.
What the USPSTF Grades Mean
The U.S. Preventive Services Task Force (USPSTF) is an independent panel of national experts in prevention and evidence-based medicine that publishes a list of recommended preventive services for all individuals. The recommendations are graded A, B, C, D, or I, based on the strength of peer-reviewed evidence and the balance of benefits and harms of the service.
Grade A – The USPSTF recommends the service. There is high certainty the net benefit is substantial.
Grade B – The USPSTF recommends the service. There is high certainty the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.
Grade C – The USPSTF recommends selectively offering or providing this service to patients based on professional judgment and patient preferences. There is at least moderate certainty the net benefit is small.
Grade D – The USPSTF recommends against the service. There is moderate or high certainty the service has no net benefit or the harm outweighs the benefits.
Grade I – The USPSTF concludes the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Jenny Berkshire, CPC, CPMA, CEMC, CGIC, is a medical and reimbursement policy coding analyst for a large Medicaid-managed care payer. She has 40 years’ experience working with providers, including 10 years as compliance manager in an academic medicine practice plan, and 13 years’ experience working as a gastroenterology coding and compliance consultant. Berkshire is a member of the Dayton, Ohio, local chapter.
JAMA Network, Evidence-Based Clinical Prevention in the Era of the Patient Protection and Affordable Care Act, Nov. 17, 2015: https://jamanetwork.com/journals/jama/fullarticle/2449698?guestAccessKey=e1df5b1c-db4e-4c16-b201-0f02a9ab1a1f
ACA, H.R. 3590: www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
MLN Matters® Articles on Medicare-covered Preventive Services: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNPrevArticles.pdf