Cindy Hughes, CPC, CFPC
Author disclosure: no relevant financial affiliations disclosed.
Published online ahead of the November/December 2016 print issue on Oct. 3, 2016.
If you have seen warnings about a huge, looming ICD-10 code update, don’t panic. The update that took effect Oct. 1 was not another new code set, just a sizable list of changes that accumulated during a code freeze enforced during the transition from ICD-9 to ICD-10.
Oct. 1 also marks the end of the Centers for Medicare & Medicaid Services grace period during which non-specific codes were accepted. You now must avoid unspecified codes when possible. You should also expect more stringent auditing of claims that include codes with unspecified laterality and other information that would be commonly known at the time of encounter.
This article highlights changes in codes, guidelines, and payer edits most relevant to family medicine. Make sure your billing system and electronic health record are updated to prevent claims denials and delays.
Current, long-term use of oral hypoglycemic drugs should be reported with code Z79.84. Report Z79.84 secondary to codes for Type 2 diabetes, secondary diabetes, or pre-existing Type 2 diabetes in pregnancy, childbirth, or puerperium. If both oral medications and insulin are used long-term, only the code for insulin use (Z79.4) should be assigned. For use of oral hypoglycemic drugs in gestational diabetes, report code O24.415. Code Z79.84 should not be reported with code O24.415. The new code for reporting prediabetes is R73.03.
A guideline change affects reporting of conditions that are associated with or due to other conditions, including diabetes. Previously, coding was dependent on documentation stating or implying a causal relationship between two conditions. A causal relationship is now assumed, unless otherwise stated, when conditions are linked by the terms “with,” “associated with,” or “due to” in the alphabetic index or tabular list. For example, nephropathy (E11.21) is assumed to be a complication of Type 2 diabetes (E11.9) unless documentation states otherwise.
New guidelines help define the episode of care when selecting the 7th character for injuries. The guidelines explain that 7th character “A” is appropriate for encounters where the patient receives active treatment for a condition that initiates the healing process. By contrast, 7th character “D” is selected for encounters after the patient has completed active treatment of the condition or, in other words, when the healing process has been established. Here is one example:
A patient is evaluated and diagnosed with a Colles’ fracture of the right distal radius. A splint is applied pending reduction of swelling. Code S52.531A is assigned because the patient is receiving active management.
The same patient returns for further treatment. Closed reduction and casting are performed. Code S52.531A is assigned because the patient is again receiving active management.
The patient then returns for follow-up. The cast is replaced due to reduced swelling. Code S52.531D is reported as this patient is now in the healing phase and active treatment has been completed.
Concussions. Codes for concussions with loss of consciousness of 31 minutes or more have been deleted (subcategories S06.0X2 to S06.0X8). Instead, see codes for more specific or unspecified intracranial injury for concussion with loss of consciousness of 31 minutes or more (S06.1- to S06.6-, S06.81- to S06.82-).
Overexertion injuries. Codes in this new category are completed with 7th characters A (initial encounter), D (subsequent encounter), and S (sequela).
A few key guidelines should be followed when reporting newborn services. Always report codes for signs and symptoms when present rather than codes in categories Z05, observation and evaluation of newborn for suspected diseases and conditions ruled out, or P00-P04, newborn affected by maternal factors and by complications of pregnancy, labor, and delivery. However, if a newborn presents without signs or symptoms but is suspected to be affected by conditions such as maternal infection or a condition resulting from the birth process that is ruled out after examination, report the appropriate code from category Z05.
If a newborn presents without signs or symptoms but is suspected to be affected by conditions such as maternal infection or a condition resulting from the birth process that is not ruled out at the end of the encounter, report the appropriate code from categories P00-P04.
Codes in category Z05 apply only from the day of birth through the 29th day following birth (day of birth is day zero). This is unlike codes P00-P04, which can be reported for as long as the condition affects the patient.
When reporting these conditions during the birth admission, the attending physician should also report a code from category Z38, liveborn infant, as the first-listed diagnosis. (For examples see, “Newborn signs and symptoms.”)
For years, Medicare and other payers have utilized age edits that resulted in inaccurate denials of “related to” conditions that began in the perinatal period or childhood but continued to exist beyond those time periods. Now all age edits for conditions that began in the neonatal period (P00-P96) have been removed, and so have edits for pediatric body mass index and for behavioral/emotional disorders that begin in childhood but may affect an adult patient. Any denials based on age conflicts should be appealed when the edits conflict with the ICD-10 code set and its reporting guidelines and instructions, which are required for use by HIPAA (Health Insurance Portability and Accountability Act).
ICD-10 uses two types of “Excludes Notes.” An Excludes 1 note indicates that two codes should not be reported together. Guidelines for Excludes 1 notes now further clarify that codes subject to an Excludes 1 note may be reported together when the codes represent unrelated conditions. For instance, an Excludes 1 note prohibits reporting teeth grinding (G47.63) in conjunction with other somatoform disorders (F45.8); however, when a patient presents with psychogenic dysmenorrhea (F45.8) and teeth grinding, it is acceptable to report both F458 and G47.63. For more information about Excludes notes, see “The Anatomy of an ICD-10 Code,” FPM, July/August 2012.
See “Other new codes of interest” for a list of additional codes that are pertinent to family medicine. To learn more about ICD-10 changes, download the full addenda and guidelines from the National Center for Health Statistics(bit.ly).
About the Author
Cindy Hughes is an independent coding consultant based in El Dorado, Kan., and a contributing editor to Family Practice Management. Author disclosure: no relevant financial affiliations disclosed.
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Encounter for desensitization to allergens Z51.6
Zika virus disease A92.5
Binge eating disorder F50.81
Disruptive mood dysregulation disorder F34.81
Persistent mood disorders, other specified F34.89
Hypertensive urgency I16.0
Hypertensive emergency I16.1
Hypertensive crisis, unspecified I16.9
National Institutes of Health Stroke Scale (NIHSS) score R29.7-(00-42)
Amblyopia suspect: right eye H53.041, left eye H53.042, bilateral H53.043
Chronic idiopathic constipation K59.04
Constipation, drug induced K59.03
Periorbital cellulitis L03.213
Pain in joints, right hand M25.541, left hand M25.542
Encounter for prophylactic fluoride administration Z29.3
Asymptomatic microscopic hematuria R31.21
Other microscopic hematuria R31.29
Other abnormal findings on microbiological examination of urine R82.79
Need to immediately revoid R39.191
Position dependent micturition R39.192
Other difficulties with micturition R39.198
Chronic bladder pain R39.82.
Encounter for initial prescription
Encounter for surveillance
Premenstrual dysphoric disorder F32.81
Pre-pubertal vaginal bleeding (cause unidentified) N93.1
Prostate specific antigen (PSA), elevated R97.20
PSA rising following treatment for malignant neoplasm of prostate R97.21
Newborn light for gestational age (weight below but length above 10th percentile), 2500 grams and over P05.09
Newborn small for gestational age (weight and length below 10th percentile), other (2500 grams and over) P05.19
Family history of sudden infant death syndrome Z84.82
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