Inpatient Facility Coding & Compliance Alert

Ward off your ICD-10 fears with these 12 enlightening facts from CMS. 

The ICD-10 tide is slowly rising and October will be here in no time! CMS urges one and all to stay prepared for the October 1 transition date, and says there will be no extensions or postponement this time.

In mid-June 2015, CMS issued a fact sheet to dispel myths and disbeliefs that loom large amongst the medical coding community. Read on for a lowdown on the most important facts that CMS aims to disseminate.

 “I think it is going to happen,” thinks Elizabeth Earhart, CPC, with Godshall Chiropractic in Millersville, PA. “We have had enough delays and the major players say they are ready (Highmark, Blue Cross, CMS, Aetna). Let’s get it over with.”

Voluntary external cause code reporting: There is no national requirement for mandatory ICD-10-CM external cause code reporting, but you may be subject to a state-based external cause code reporting mandate or these codes may be required by a particular payer. However, CMS encourages you to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies.

Increase in codes makes them easier to find: CMS implores you not to get intimidated by the increase in number of codes. According to CMS, the greater number of codes in ICD-10-CM/PCS makes it easier for you to find the right code. 

The Alphabetic Index and electronic coding tools are available to help you select the proper code. Because ICD-10-CM/PCS is much more specific, is more clinically accurate, and uses amore logical structure, it is much easier to use than ICD-9. 

More codes for signs and symptoms: Although assigning an ICD-10 code requires furnishing a lot of information, rest assured that you would not need to perform a lot of medically unnecessary diagnostic tests for that purpose. As with ICD-9, ICD-10 codes are derived from documentation in the medical record. Therefore, if a diagnosis has not yet been established, you should code the condition to its highest degree of certainty (which may be a sign or symptom) when using either coding system. In fact, ICD-10 contains many more codes for signs and symptoms than ICD-9, and it is better designed for use in ambulatory encounters when definitive diagnoses are often not yet known. Nonspecific codes are still available in ICD-10-CM/PCS for use when more detailed clinical information is not known.

Dare the documentation devil: As always, the codes have to be based on medical record documentation. Now, to your pleasant surprise, much of the detail required in ICD-10 probably is already there in your medical record documentation and just is not currently needed for ICD-9 coding.

Although documentation supporting accurate and specific codes results in higher-quality data, you can still find nonspecific codes for use when your provider’s documentation doesn’t support a higher level of specificity. 

No ado about superbills: Do not worry that the ICD-10 based superbills will tend to be too long or too complex. In its true spirit, a superbill should contain the most common diagnosis codes used in the practice. Neither your presently-used superbill nor your ICD-10 based future superbill should aim to provide all possible code options for many conditions. To generate your ICD-10 based crisp superbill, you might: 

• Review your present superbill to eliminate diagnosis codes that you don’t see often; and

• Generate an ICD-10 equivalent code list by looking up codes in the ICD-10 code book or using the General Equivalence Mappings (GEMs).

“Our superbill only shows the top four codes used,” admits Earhart. “If the doctor needs to change the diagnosis, he does so in his documentation. It is my job to catch those changes and bill accordingly.”

Understand the difference between mapping and coding: Remember that the GEMs were not developed to provide help in coding medical records. We have code books to do that. Moreover, mapping is different from coding because:

• Mapping links concepts in two code sets without consideration of patient unique actual clinical condition as per the medical records.

• Assignment of the most accurate code is based on the documentation and appropriate coding guidelines.

You can use GEMs to convert not just the diagnosis codes, but also figure out changes in payment systems; payment and coverage edits; risk adjustment logic; quality measures; and a variety of research depicting clinical trends in population.

How best to use GEMs: Each payer will be required to develop their own mappings between ICD-9 and ICD-10 as the GEMs developed by CMS and the Centers for Disease Control and Prevention (CDC) are for Medicare use only. The GEMs are a crosswalk tool that was developed by CMS and CDC for the use of all providers, payers, and data users. The mappings are free of charge and are in the public domain.

Is ICD-10 outdated already? Not at all! The ICD-10 codes had been updated regularly since their original development to keep pace with advances in medicine and technology and changes in the health care environment. On Oct. 1, 2015, only limited code updates for new technologies and new diseases will be made to the ICD-10 code sets to capture new technologies and diseases. On Oct. 1, 2016, regular updates to ICD-10 will resume.

ICD-10-PCS and CPT®: ICD-10-PCS will only be used for facility reporting of hospital inpatient procedures and will not affect the use of CPT®.

ICD-10 and HCPCS: Remember that the ICD-10 codes will not impact your CPT® and Healthcare Common Procedure Coding System (HCPCS) codes reporting. This also includes CPT®/HCPCS modifiers for physician services. While ICD-10 codes have expanded detail, including specification of laterality for some conditions, you should continue to follow CPT® and CMS guidance when you report CPT®/HCPCS modifiers for laterality.

Non-covered entities to fall in line, too: It is in the best interest of entities not covered by HIPAA such as Workers’ Compensation and auto insurance companies, to use the new coding system because ICD-9 will no longer be maintained after ICD-10-CM/PCS is implemented.

Moreover, the increased detail in ICD-10-CM/PCS is of significant value to non-covered entities. 

State Medicaid Programs to gear up: State Medicaid Programs will also be required to update their systems to use ICD-10-CM/PCS codes, because HIPAA requires the development of one official list of national medical code sets. 

Final takeaway: Integrate this timely piece of advice from CMS in your preparations for the transition, and breathe easy when October arrives. “Start testing now,” decrees Earhart. “Dual code if you can, and communicate with your payers. If they allow, submit bills for testing with ICD-10 codes. Self audit where you can, and stay positive. I wasn’t around when ICD-9 happened, but my boss was. The difference between now and then is the quicker turn around and the ability to do everything electronically.” 

For more information, visit:

http://www.cms.gov/Medicare/Coding/ICD10/downloads/icd-10mythsandfacts.pdf.