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.
September 27, 2016
Guest Bio:
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.
