Outpatient Facility Coding Alert

Published on Mon Jul 28, 2014 PDF

Be equipped with the plan of action to embrace the new system 

The notion that outpatient services will not be affected by the ICD-10 transition is creating a false complacency in outpatient coders which might lead to a significant number of claim denials and underpayment of rightful claims.

Background: ICD-10 is divided into two parts: the ICD-10-CM diagnostic codes, and the ICD-10-PCS procedure codes. It is a fact that that ICD-10-PCS will be used exclusively to code procedures provided for inpatient services, while the majority of payers will continue to accept the most current edition of CPR® codes for outpatient procedure claims. However, the ICD-9 codes will be completely replaced by ICD-10-CM diagnostic codes. And, the insurers will judge the appropriateness of the bills based on the new diagnostic codes.

The problem area: A blogger from Santa Rosa Consulting, which conducts impact assessments for the ICD-10 transition writes, “If you ask an organization about who does outpatient diagnosis coding at their facility you’ll typically find there are lots of departments and fingers involved,” and “Worse, they often can’t tell you specifically who does the coding or how coding is accomplished for all of the types of outpatient visits to the facility.” 

Plan of action: The first step toward preparation should be to identify people responsible for outpatient coding and ensure that they are well versed and adequately educated and trained in the new ICD-10 system of coding along with the current CPR® codes.

The claims submitted should also have satisfactory diagnostic justification before your claim will be approved. Inappropriate bills lead to Medicare denial and audits, which could cost providers a significant amount of money in the form of retracted reimbursements. 

See the Comparison and Know the Difference 

A detailed comparison shows how different the two diagnosis coding systems are. In ICD-10 you’ll need a good understanding of anatomy and physiology, medical terminology, and the procedures being performed. Time and training are required to get familiar with the new requirements and the new system.

Take Your Cues From This Case Study

A run-through of a cystoscopy procedure will show how to assign the ICD-10-CM codes in the outpatient setting. Details from the note follow: 

Postoperative diagnosis: Left ureteral calculus

Procedures: Cystourethroscopy, left retrograde pyelogram, left ureteroscopy with stone, and extraction and stent placement 

Anesthesia: General

Procedure Description: After informed consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. He was then given a general anesthetic and placed in dorsal lithotomy position, prepped and draped sterilely. 

Cystourethroscopy was performed using a 21-French rigid cystoscope with video assistance, which showed a normal anterior urethra. Prostatic urethra was also normal, consistent with minimal, if any, BPH (Benign prostatic hyperplasia)

Upon entering the bladder, there was some cloudy urine coming from the left ureteral orifice. A retrograde pyelogram with contrast was then performed using a 50:50 mix of Conray and sterile water, and an 8-French cone-tip catheter. This showed several small filling defects in the distal ureter, approximately a centimeter up from the ureteral orifice. This was consistent with the stone seen on the CT. The cystoscope and the cone-tip catheter were then removed.  A 0.035 French Sensor Dual-Flex guidewire was then passed through the cystoscope and up into the renal pelvis and coiled under fluoroscopic guidance. 

The Olympus 9-French ureteroscope was then used to perform distal rigid ureteroscopy. The stone fragments were seen at the distal ureter. The doctor successfully basketed the three largest fragments of stones and sent them to pathology for evaluation.  The remaining stones were too small to be retrieved successfully using the 1.5-French stone basket.

Following this a 4.6 x 30 cm double J ureteral stent was placed without difficulty. The patient tolerated the procedure well. His bladder drained, and he was taken to recovery in stable condition. 

Code the claim: The following table gives a comparative picture of both systems of coding.

The first table below shows a comparison of the ICD-9 diagnosis codes and the ICD-10 diagnosis codes. The descriptors are similar.

ICD-10-CM identifiers: Look at the interesting pattern of naming the code. Each digit of the ICD-10 diagnosis code is a specific identifier, and this is how the above code would be interpreted: N = Chapter 14 — Disease of Genitourinary System; 20 = urolithiasis; .1 = ureter. In other words, ICD-9’s 592.1 (Calculus of ureter) becomes N20.1 (Calculus of ureter). 

PCS similarity: If you see the ICD 10 procedure codes, you would see the descriptor differs, for example, 57.32 (Cystoscopy, other) of ICD-9-CM changes to 0TC78ZZ (Extirpation of Matter from left ureter, via natural or artificial opening, endoscopic) in ICD -10-PCS.

Keep in mind that in the outpatient setting ICD-9-CM procedure codes would not be reported (per Health Insurance Portability and Accountability Act [HIPAA] guidelines), but they are provided for illustrative purposes.  

Like the ICD-10 diagnosis codes, each digit in the ICD-10-PCS column identifies a specific feature: 

• 1st character: 0 = medical surgical and B = imaging;
• 2nd character: T = urinary system; 
• 3rd character: C = extirpation, 7 = dilation, and 0 = plain radiography; 
• 4th character: 7 = left ureter; 
• 5th character: 8 = endoscopy via natural opening and Y = other contrast; 
• 6th character:  Z = no device and D = intraluminal device; 
• 7th character: Z = no qualifier. 

Assign CPR® Procedure Codes

 For the above outpatient case, you also will need to assign the following CPR® procedure codes:

• 52352  Cystourethroscopy with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)
• 52332  Cystourethroscopy with insertion of indwelling ureteral stent...

The following code is bundled into code 52352 and, per National Correct Coding Initiative (NCCI) edits, should not be assigned:

52005  Cystourethroscopy with ureteral catheterization with or without irrigation, instillation or ureteropyelography, exclusive of radiologic service.