ICD 10 arrives October 1st and many of you are in the final stages of preparation for this important transition. As you prepare, I'd like to offer you a few tips for making sure you're ready.
Tip #1: Sequence your codes appropriately.
ICD-10 provides more rules for sequencing than its predecessor. The most complex condition is sequenced first, following any code first/code also rules that apply. If the codes is an injury (Chapter 19) or has neurologic components, this is normally the primary diagnosis. The second tier of importance are structural codes, followed by functional codes, followed by soft tissue codes.
Example: Piriformis syndrome, left side G57.02 sequenced before spinal stenosis, cervical region M48.02
Tip #2: Initial Encounter Active Care.
That pesky 7th character seems to be throwing everyone for a loop, so I recommend that we simplify our approach for now. My recommendation at this point in the game is to use only initial encounter active care: the extension A. Given the information we can discern from the coding guidelines and Medicare LCDs the use of the extension A represents care that meets medical necessity guidelines. Commercial payers have offered little insight into their interpretation of the new concept, but the value of D (subsequent encounter), appears to be limited to maintenance visits. Sequela (extensions of S) visits have some coverage under Medicare LCDs, but until we get further direction on the expectations surrounding the use of this extension, my advice for now is simply use the active care (extension A) and avoid the controversy.
As guidance from commercial payers is provided we’ll keep you updated.
Tip #3: Diagnose your patient from 30,000 feet.
What does that mean? Change your perspective. ICD 10 is a complete redesign of coding and therefore using a crosswalk to create a one to one relationship between your ICD-9 and ICD 10 codes will often result in incorrect diagnoses for your patients.
Example: Patient presents in your office with symptoms in only the lumbar area.
Your ICD-9 DX coding is:
722.10, 724.4, 729.1 (herniated lumbar disc, radiculopathy, myalgia)
Using the crosswalk your code selection may result in this incorrect code selection:
M51.26 – Other intervertebral disc displacement, lumbar region
M54.16 - Radiculopathy, lumbar region
M79.1 - Myalgia
The correct code selection is M51.16 IVD w/radiculopathy
Less is often more.
Tip #4: Signs and symptoms are coded when we do not know the underlying cause.
This rule is one that I have discovered doctors are struggling to accept. In the past, many doctors included codes for all the patient’s symptoms in an effort to paint a more complete picture. In the previous example the lumbar muscle pain was diagnosed (729.1) in ICD-9, but implied under ICD-10 as it commonly occurs with the primary condition. This will take practice and discipline to implement!
Tip #5: Pain is a pain.
Pain coding is one of those areas that complicates tip #4. If you have identified the cause of the pain, then the need to add a code to identify the symptom is not needed. Read that sentence again because it is a shift from what you might be used to doing! If you are treating the underlying cause of the pain, then the pain coding is superfluous.
When do you code pain? Pain is coded under two situations:
- The underlying cause of the pain isn’t known.
- The primary reason for the visit is pain control.
You can also add codes to indicate acute vs. chronic pain.
Example: Patient presents with chronic right elbow pain. Radiology shows no obvious reason for the pain and the patient denies trauma to the area. This visit can be coded as:
M25.521 – Pain in right elbow
G89.29 – Other chronic pain
You’ve been working for months on this. You’re stressed and trying to remember all the rules. Is it this code or that code? Add a code? Drop a code? What if I miss one? This ICD-10 transition is giving you an episodic tension headache.
This is a new adventure and everyone is in the same position. There will be bumps in the road, clarification from payers, and lots and lots of opinions flying around. Give it your best shot and make sure your documentation supports your code selection. If denials happen, get some assistance and be flexible enough to know that changes will happen. Seek assistance when you need it and try not to sweat the small stuff. All your preparation will be worth it.
Relax, you’ve got this.