CureMD: Big changes are coming on October 1st . Can you briefly discuss what they are and why practices need to be prepared?
Dr.Gwilliam : Two things happen on October 1st. It is the first update to ICD-10 since the codes were frozen back in 2012 and the end to the 1 year medicare grace period offered in 2015 to help practices transition to ICD-10.
Both have the potential to affect your bottom line if you are not prepared. However, not all practices will face the same challenges. For example, many commercial payers had demanded full level of specificity while coding for ICD-10 from the beginning. Practices dealing with such payers will now need to replicate this for medicare as well. For others, more nuanced clinical documentation and increased specificity will be required.
As far as changes to the code set go, there are amendments to both procedure (PCS) and diagnostic codes (CM). For ICD-10 PCS there is an increase of 3,651 new codes, with 487 revised code descriptions. Approximately 5,400 codes will be added, changed, or deleted.
For ICD-10 CM, 2017 will include 1,943 new codes, 305 deleted codes, and 422 revised codes. The good news is that these annual updates will probably not be as major in the future. Practices need to figure out which changes apply to them so that payers can get accurate information on claims
CureMD: The magnitude of the change seems huge. Can you break them down for us?
Dr.Gwilliam : First and foremost there are three separate components to the update:
- Official guidelines for coding and reporting in ICD-10 have been amended. Here is a summary of what some of these changes are.
- The Alphabetic index has new categories added to it.
- There are some tweaks in the tabular list as well.
Though it is tempting to directly jump onto the code changes, I would advise you to work systematically through these changes by looking at the guidelines, the alphabetic index and the tabular list in your preparation.
Here are a few key points. For more information you can watch the first fifteen minutes of the webinar I conducted alongside CureMD.
- An important change in the guidelines is how to interpret the word “with”. This change is extremely important for primary care, cardiology and OB practices . Moving forward the word “with” should be interpreted to mean “ associated with”or “due to” when it appears in a code title, the alphabetic index, or an instructional note in the tabular list.
- Similarly the word “And” should be interpreted to mean either “and” or “or” when it appears in a title.
- As mentioned earlier both Procedure and Diagnoses codes have been added, deleted or revised.
- Out of the 5,400 changes to ICD-10 PCS , 3,549 (97 percent) represent changes to the cardiovascular system. These changes are going to specifically affect stent placement and CABG coding. We will be going back to the “old” ICD-9 way of coding CABGs and stent insertions – by counting arteries and number of stents by stent type. The significance of this revision means that coronary artery anatomy review will be an important piece of coder preparation, because coding the placement of two stents placed in different portions of the LAD today will be different on or after Oct. 1, 2017.
- Other new codes include expansion of body part detail in the removal and revision of lower joints. Another addition is the unicondylar knee replacement.
You can view the full list of changes to ICD-10 PCS in 2017 ICD-PCS Conversion Table.
ICD-10 CM 2017
- There are many changes to the Includes, Excludes and the list of codes included within each code.
- Many new codes are a result of expanding the laterality options in many categories including several fracture categories and the Diabetes with ophthalmic manifestation code category. For example, there are hundreds of revisions and improvements (299, to be exact) to the diabetes mellitus codes. Documentation improvement for diabetes mellitus is discussed in detail in CureMD webinar on ICD-10.
- With these new laterality code, the Musculoskeletal Disorder section has the newest codes.
- Also the diagnosis listed in the “other categories” have been assigned some new codes in several categories.
- There are better coding options for contraceptive management.
- Additional clinical guidance for nicotine dependence along with examples.
For a detailed discussion on updates for ICD 10 CM 2017 we recommend this webinar.
CureMD: Would the changes to ICD-10 codes affect all specialties equally?
Dr.Gwilliam : No. Some chapters, such as infectious diseases, will only have a few minor changes, while others have much more. Thus, some specilaties will have their work cut out while for others there are very few amendments. Details for chapter wise changes are listed below :
CureMD: During the grace period, payers took a conservative approach on creating additional claim review criteria. What are some expected payer behavior changes once the ICD-10 grace period ends?
Dr.Gwilliam : It would be wise to self-audit the top ten diagnoses in your practice. Become very familiar with the code options for those conditions and create Problem Statements that concisely support the codes. It is possible that payers will ask for records more often than in the past, and they will compare the record with the codes.
CureMD: What are some workflow changes a practice should undertake to code accurately post grace period ending?
Dr.Gwilliam : The processes most likely won’t change, but it would be wise to dedicate some time each week to documentation improvement. Then, at the point of patient care, the providers can learn to create ICD-10 proof records.
Practices should take out time to get familiar with their most frequently assigned unspecified codes and work on them, with a priority to heighten the awareness of which situations contribute to their assignment. Run a report from the financial or coding system and see which codes are being assigned that are unspecified, then work to prioritize and reduce their prevalence through concurrent queries, EMR remediation, and physician education.
CureMD: When is the usage of unspecified codes appropriate?
Dr.Gwilliam : Only when it is the best option, given the documentation. Most of the time, providers should be able to provide documentation that supports a more specific code. Be prepared for payers picking on unspecified codes even more now that the CMS grace period is over.
However, do not pressurize your physicians to use a specified code when the patient’s condition does not warrant it. Here are three things that make a difference and help you decide whether to use such as code :
- Location of the service
- Who is providing the service
- Where are we with the treatment plan
For example, a patient comes in the emergency room ( location ) with abdominal pain and tells you he has pancreatic cancer. In that setting, it is probably not reasonable to expect the patient to know if it’s head, body or tail of the pancreas. You are currently treating him for abdominal pain. In that location an unspecified code for pancreatic cancer is appropriate and will put abdominal main in a potential context. Now, if the location of that abdominal pain is in an office visit to an oncologist ( a specialist) the lack of specification is not as acceptable.
Read more: The Appropriate Use of Unspecified Codes in ICD-10
CureMD: How can practices approach occasional denials with unspecified codes submitted by private payers?
Dr.Gwilliam : Practices need to carefully evaluate these denials to make sure that there is not a better code available. If the unspecified code is justified (i.e. the provider really does not know the details necessary), then be prepared to explain that rationale to payers.
CureMD: Better documentation leads to a better bottom line. What are some strategies for clinical documentation improvement that work really well for small practices?
Dr.Gwilliam : Small practices need to appoint a champion of documentation improvement. This person can create Provider Documentation Guides (or obtain them from Find-A-Code) and meet with providers to discuss and learn together. There is no need to spend big money on consultants or courses. An understanding of the code set is all you need to be able to answer your own questions.
Watch ICD-10 Documentation Improvement Strategies by Dr. Evan Gwilliam
CureMD: The new guideline instructing coders not to use clinical indicators for code assignment has generated considerable interest. Here is a list of coder behaviors in a practice. Keeping in mind the need of specificity and increased payer audits what would be an ideal process for coders to assign codes?
Option 1: Query physician but assign codes based on clinical criteria regardless of query response and physician documentation
Option 2: Query physician and assign codes based on physician query response and documentation regardless of clinical criteria documentation
Option 3: Skip the query and assign codes based on clinical criteria regardless of physician documentation
Option 4: Skip the query and assign codes based on physician documentation regardless of clinical criteria documentation
Option 5: Physicians do their own coding
Dr.Gwilliam : In an ideal world, Option 5 is the best in terms of coding accuracy. This assumes that the providers are ICD-10 experts. Unfortunately, the demands of practice mean that there just is not enough time, and in some cases, will power. Therefore, an expert on staff should work with providers until they become familiar with the documentation requirements for their most commonly coded conditions. A carefully crafted query may be very fruitful, but the coder needs to know what to ask, based on the specifications of the code set.
CureMD: How can practices get ready to face off with more codes and the conclusion of the grace period?
Dr.Gwilliam : Watch the webinar that CureMD and Find-A-Code put together. Then look into the code changes that were mentioned that apply in your practice. And consider the strategies given for documentation improvement. Try both, or pick one that better fits your practice style.
CureMD: What are the benefits of better ICD-10 coding that practices can look forward to?
Dr.Gwilliam : If the documentation is good enough to support specific codes, payers will adjudicate claims more fairly. That is, if they have more information because the codes are more accurate, they won’t waste time with recorded reviews and denials based on unspecific diagnoses.
Moreover, data for quality reporting program such as MIPS will continue to come out of your claims. By coding to the highest specificity now with clinical documentation supporting your claims you will be putting your practice on a path to MACRA success.
CureMD: Are there any other changes to be expected after the end of the Grace Period?
Dr.Gwilliam : Next year, the committee on ICD-10 changes will meet again, and we can watch for the transcripts from that meeting. Updates will occur annually, so expect more changes next October.
Dr. Evan Gwilliam is a clinician by profession who, in his own words, “wishes to bridge the gap between clinicians and coders by simplifying ICD-10.” He is a self-proclaimed certification junkie, with credentials such as a Certified Professional Coding Instructor, a Medical Compliance Specialist, and a Certified Professional Medical Auditor. He now provides expert witness testimony, medical record audits, consulting, and online courses for health care providers. He also writes books and articles for trade journals, and is a sought-after seminar speaker. He is the vice president and chief product officer of the ChiroCode Institute and Find-A-Code that provides coding, documenting, and reimbursement guidance and education to physicians and coders. Dr.Gwilliam has a Bachelor’s degree in accounting and a Master’s degree in Business Administration. He is also one of the few clinicians who became certified ICD-10 Instructors through the American Academy of Professional Coders.