General Surgery Coding Alert

Never miss listing all required digits.

If you’ve been relying heavily on CMS’s year-long “free pass” to avoid ICD-10-CM claims denials, get ready for that grace period to end on Oct. 1. You’ll recall that your surgery practice simply had to report a diagnosis to the proper family to avoid denials ever since ICD-10-CM went into effect last fall.

Beware: The end of the grace period may result in an increase in denials if you haven’t been applying the level of specificity ICD-10 truly requires, says ICD-10 trainer Monica Smith, RHIT, CPC, CRCR, an associate in Kraft Healthcare Consulting’s compliance services division.

Between the sunset of claims leniency and the recent release of the final ICD-10-CM 2017 addenda (effective Oct. 1), you need to make sure you’re ready to report timely and complete diagnosis codes on every claim.

Be Specific to Avoid Denials

Make sure you always assign an ICD-10-CM code based on the most specific, certain diagnosis available to you. According to coding guidelines, you should not “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

For surgeons, that means you might want to wait for the pathology report to file your claims. If not, you’ll be left coding vague signs and symptoms, such as N63 (Unspecified lump in breast) for a breast biopsy, instead of a specific code such as C50.-- (Malignant neoplasm of breast…) based on the final diagnosis.

Opportunity: The final diagnosis might impact your surgical procedure code selection. For instance, you’ll choose different procedure codes for benign versus malignant lesion removal (such as 11446, Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm, versus 11646, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm). The payoff for properly identifying the procedure as a malignant lesion excision is $127.46 more than for the benign lesion excision (based on 2016 Physician Fee Schedule national non-facility amount, conversion factor 35.8043, which is $524.53 for 11646, and $397.07 for 11446).

Avoid ‘Truncated’ Codes

If you report a code that doesn’t include the full range of digits required to be a complete code, that’s called a truncated code — and that’s bad. If the code requires a fourth, fifth, sixth, or seventh digit, you can’t just leave off the extra digits because you don’t have specific information. Most categories that require extra digits include “unspecified” or “not elsewhere classified (NEC)” codes that you can use if you don’t have more specific information.

Do this: Always report ICD-10-CM codes to the highest level of specificity required. If you report a truncated code, don’t be surprised by a claim denial for lack of medical necessity.

Especially now: You can expect denials starting Oct. 1 for claims that don’t list the ICD-10-CM code to the most accurate, complete level — even if the claim would have passed muster during the grace period.

Prep Now for ICD-10 2017

Even if your coding and documentation were perfect in 2016, you’ll need to put in some work to be sure you can maintain your accuracy rate once the 2017 changes go into effect.

“Educate and train on the 2017 ICD-10 CM changes,” says Marchelle Cagle, CPC, CPC-I, PCS, of Cagle Medical Consulting in Birmingham, Ala.

Also ensure that you’ve ordered your 2017 ICD-10 CM books, Cagle says.

Resources: The ICD-10 CM changes are also published here: www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html. Plus, “there are many free webinars out right now to ensure a practice gets ICD-10 CM change training,” Cagle adds.

Tip: To see some ICD-10-CM changes you’ll need to know for your general surgery practice, review “ICD-10: Get Ready for Dx Updates This October” in General Surgery Coding Alert vol. 18 no. 6, and turn to page 68 in this issue to read “Recognize Abdominal Diagnosis Options Coming Your Way.”