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 marked 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 claim 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 associated with or due to other conditions, including diabetes. Previously, coding depended on whether the documentation stated or implied a causal relationship between the 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 is assumed to be a complication of Type 2 diabetes unless documentation states otherwise.
New guidelines help define the episode of care when selecting the 7th character of an ICD-10 code 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 – 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 concussion 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- and 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).
X50.0XX- Overexertion from strenuous movement or load,
X50.1XX- Overexertion from prolonged static or awkward postures,
X50.3XX- Overexertion from repetitive movements,
X50.9XX- Other and unspecified overexertion from strenuous movements or postures.
Conditions in the newborn
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 a condition 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 a condition 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.”)
|On the day of birth, a newborn is asymptomatic but monitored for signs of infection from maternal exposure. Lab work is pending at the end of the encounter.||The physician reports code P00.2, newborn (suspected to be) affected by maternal infectious and parasitic disease.|
|On the day after birth, the newborn remains asymptomatic and lab results are normal. Examination rules out infection.||The physician reports code Z05.1, observation and evaluation of newborn for suspected infectious condition ruled out.|
|A 6-day-old newborn is seen in the clinic for parent concerns that the newborn is breathing irregularly. After examination, there are no abnormal findings.||The physician reports code Z05.3, observation and evaluation of newborn for suspected respiratory condition ruled out.|
|A 6-day-old newborn is seen in the clinic for parent concerns that the newborn is vomiting after feedings. After examination, the diagnosis is newborn regurgitation.||The physician reports code P92.1, regurgitation and rumination of newborn.|
For years, Medicare and other payers have utilized age edits, resulting in inaccurate denials of claims with “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 began in childhood but may affect an adult patient. Any denials based on age edits should be appealed when the edits conflict with the ICD-10 code set and its reporting guidelines and instructions, which providers are required to use under HIPAA.
Exclusion note changes
ICD-10 uses two types of “excludes notes.” An Excludes 1 note indicates that two codes should not be reported together. Guidelines now 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.
Other new codes
|Encounter for desensitization to allergens Z51.6||Encounter for initial prescription:|
|Infectious disease||vaginal ring hormonal contraceptive Z30.015|
|Zika virus disease A92.5||transdermal patch hormonal contraceptive device Z30.016|
|Behavioral/Mental health||implantable subdermal contraceptive Z30.017|
|Binge eating disorder F50.81||Encounter for surveillance:|
|Disruptive mood dysregulation disorder F34.81||vaginal ring hormonal contraceptive device Z30.44|
|Persistent mood disorders, other specified F34.89||transdermal patch hormonal contraceptive device Z30.45|
|Cardiovascular||implantable subdermal contraceptive Z30.46|
|Hypertensive urgency I16.0||Premenstrual dysphoric disorder F32.81|
|Hypertensive emergency I16.1||Pre-pubertal vaginal bleeding (cause unidentified) N93.1|
|Hypertensive crisis, unspecified I16.9||Male genitourinary|
|National Institutes of Health Stroke Scale (NIHSS) score R29.700-R29.742)||Pain:|
|Amblyopia suspect: right eye H53.041, left eye H53.042, bilateral H53.043||right testicular N50.811, left testicular N50.812|
|Gastrointestinal||Prostate specific antigen (PSA), elevated R97.20|
|Chronic idiopathic constipation K59.04||PSA rising following treatment for malignant neoplasm of prostate R97.21|
|Constipation, drug induced K59.03||Neonatal|
|Integumentary||Newborn light for gestational age (weight below but length above 10th percentile), 2500 grams and over P05.09|
|Periorbital cellulitis L03.213||Newborn small for gestational age (weight and length below 10th percentile), other (2500 grams and over) P05.19|
|Musculoskeletal||Family history of sudden infant death syndrome Z84.82|
|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|