Coders allowed to change ICD codes after 10/1/16


Columbus, Ohio
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I have a colleague who is insisting coders are no longer allowed to changed diagnosis codes after 10/1/16, even if the documentation provided proves a different code. She is under the impression this is a CMS rule. Does anyone have information on this or the specific link from CMS that talks about this? It doesn't make sense to me that a code couldn't be changed if its found to be billed in error based on the documentation??


True Blue
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More like she should provide you backup documentation from CMS about this. I have not heard such a thing. I know the ICD-10-CM guidelines were updated to clarify that you cannot assign diagnosis using the same clinical criteria a physician would used but that just means you are not a doctor and cannot try to read between the lines in the documentation. if its documented properly and just coded wrong there is no reason you cannot change to the correct code.


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I do not understand when how a viable Diagnosis based on a lab result, path BX result, or diagnostic imaging rept would not qualify to better assign an actual DX over a SX... (even if not from the original MD) for example, MRI Lumbar scan (DX on refferal order from PCP is LBP Lower back pain) the report a Radiologist who is a MD states multiple wedge vertebral fractures due to osteoporosis... this pt would require surgery or vertebralplasty! How would you prove medical necessity for surgery if the back pain (a symptom) was used for the actual Diagnosis on the MRI claim??? This would also be true in pathology reporting, say gyne preforms hysteroscopy w/ BX.. due to abnormal pap smear result... and path rept states endometrial cancer??? You would append the Path result ...this pt requires a hysterectomy!!!
I agree with the abuse of billing coders up-coding for LCD/NCD requirements to get a claim paid is the wrong reason. However if a report is available to expound or confirm a diagnosis rather than a symptom on the referral or chart note.
Also EHR programs still chart in ICD 9 and the "auto crosswalk is unspec" like shoulder pain... must be rt or lt in ICD 10. CPC's must have the ability to assign the correct code to some degree. PERFECT EXAMPLE IS ICD 9 722.10 radiculopathy and ICD 10 has over 20 codes which replace this one code! Knowledge is the key