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8 things you need to know about ICD-10-CM/PCS

Despite evoking a tepid response when proposed, most of the medical community has made the shift to ICD-10 and must now prepare to acquaint their Health IT systems and train their Medical coding staff regularly with the yearly updates released by CMS. According to CDC, ICD-10CM/PCS has an improved structure, capacity, and flexibility for capturing advances in technology and medical knowledge.

For the upcoming FY 2017, effective Oct.1,2016, CDC has come up with new additions, changes and revisions in ICD-10 CM and PCS codes, which are now available on the CMS website. It is vital for the health care provider, payer and coder to orchestrate efficiently for complete and accurate documentation and reporting of diagnosis and procedural codes, which can further have an impact on claims processing and the total revenue cycle management.

There have been 1974 additions, 311 deletions, and 425 revisions, giving us a total of 71,486 ICD-10-CM codes. With the ICD-10-PCS codes, there has been a significant rise in the number of cardiovascular codes that were added, that came up to 97% of the total code additions. CMS, as expected, managed to add a slew of new codes and jargon to the healthcare coding lexicon.

Here are the eight important things about ICD-10-CM/PCS that you need to know for the upcoming FY 2017.

  1. 1. Clarification on “with” & “and”

   When the word “with” appears in a code title, Alphabetic index or a physician description, the two conditions linked by this term should be considered as related and coded accordingly, unless mentioned by the Physician as unrelated. For example, when a diagnosis of Nephrotic syndrome with Dyslipidemia is documented by the physician, these two conditions are to be considered as related. If these two conditions are stated separately without any correlation, they should be coded separately for billing.

When the word “and” is documented in a diagnosis such as Metastasis to brain and spine, it should be interpreted as fracture of radius and/or ulna. But, if the physician writes the diagnosis as “Fracture-forearm”, it should be coded differently.

  1. Code Assignment and Clinical criteria

Codes are to be assigned based on the provider’s diagnostic statement that the condition exists in the patient. But the clinical criteria, based on which the provider diagnosed the patient’s condition need not to be taken into account. To exemplify this further, let’s consider a patient  diagnosed of Stage II ovarian cancer, code assignment should be based on the diagnosed condition but not based on whether the physician chose TNM/FIGO classification for diagnosing it.

  1. Laterality

Bilateral conditions such as B/L hearing loss, glaucoma, nerve palsies or stroke should be billed under the “bilateral” code when the condition exists on both the sides. Even if one side is treated first in a visit followed by the other side in a different encounter, this rule applies. This rule does not hold if one side is treated and cured and the condition no longer exists, then unilateral code for the affected side is to be assigned.

  1. Non-Physician and technician documentation

Assigning of codes for Body Mass Index, description of non-pressure chronic ulcers, staging of pressure ulcers, coma scale and NIH stroke scale(NIHSS) codes can be based on the documentation made by the allied health Non-Physicians/clinicians who are legally accountable for establishing the patient’s diagnosis. However, the associated diagnosis of Diabetes, Obesity, acute stroke or pressure ulcer must be made by the patient’s provider.

  1. Codes for Zika virus

The much awaited codes for Zika virus have been added under the Infectious and parasitic diseases chapter. A92.5 code can now, be assigned to all confirmed cases of Zika, irrespective of the mode of transmission and diagnostics. Physician’s documentation of confirmation will suffice. If the physician documents “suspected”, “possible” or “probable’ Zika, then codes for the respective symptoms such as fever, rash or joint pain should be assigned or code(Z20.828) for contact with and suspected exposure to other viral communicable diseases can be assigned.

  1. Diabetes and Hypertension

According to CDC, 9.3% of the American population have been diagnosed with Diabetes and 29.1% with Hypertension. With the ever increasing incidence of these conditions a new code has been added for long term (current) use of oral hypoglycemic drugs(Z79.4) and Secondary Diabetes. We, previously could only code for long term use of insulin. In a case of Gestational Diabetes, treated with both diet and oral hypoglycemic, code for controlled with oral hypoglycemic drugs should be applied.

When conditions of the heart and kidney are stated along with Hypertension, linked by the term “with”, such as Hypertension with CKD (Chronic Kidney disease), these conditions are to be coded as related as mentioned above. If a patient has a heart condition/CKD not related to Hypertension and also has Hypertension, these conditions should be coded separately. Codes from combination category I13 should be assigned when there is hypertension with both heart and kidney. Codes from combination category I13 should be assigned when there is hypertension with both heart and kidney involvement. Code from category I16 should be assigned for documented hypertensive urgency or emergency or crisis. The primary code for any identified hypertensive disease is based on the reason for patient’s visit.

  1. OB and Neonatology

 Codes from category-O09-supervision of high risk pregnancy should be assigned only during the perinatal period. If a high risk patient, delivers normally, codes for the encounter of full term normal delivery should be assigned. When an obstetric patient is admitted and she delivers during the same admission, codes should be assigned based on which condition lead to the admission. If there are multiple conditions, that lead to admission, the one which is most related to the delivery should be assigned first followed by codes for any kind of complications that may have occurred.

Codes from category Z05 should be assigned for observation and evaluation of newborns for suspected conditions and when they are ruled out. Hence, this code should only be applied to healthy newborns. If the newborn has any signs or symptoms, codes for those signs and symptoms should be assigned. Z05 can be assigned for readmissions and also be used as a secondary code after the primary code Z38 is applied.

  1. Abnormal findings and Multiple concepts

ICD-10-CM Official Guidelines for Coding and Reporting defined an examination with abnormal findings as “A condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination”. When a general examination reveals an abnormal finding, the code for the general examination with abnormal findings should be assigned to the first listed diagnosis. Then, secondary code for the abnormal finding should be assigned next.

If a diagnosis such as end stage renal disease with acute pulmonary edema is made, both acute and chronic conditions need to be present on admission so that the coder can assign  “Y” to the codes that contain multiple clinical concepts.

About Xybion Health

Xybion Health brings Digital, Cloud and IoT (Internet of Things) to Workers’ Comp., Occupational Health, Occupational Medicine and Injury Management .

Xybion’s Emidence™ is a unique, digital workplace in the cloud and on mobile platforms where all stakeholders: Employers, Employees, Health care providers, Case Managers, Bill reviewers, Payers and Regulators, comes to work utilizing security based permissions to seamlessly create, share and move core data on the injured person and claims while complying with guidelines  and regulations. .  ACOEM, ODG, OSHA, digital ICD-10 billing and digital Bill Review are all built in the same platform for seamless workflow and process management. Emidence™ platform empowers sophisticated risk management program executions, Integrates injured-worker advocacy and engagement through patient portals, evidence based medical care, real time digital case management, digital bill review and claims management. Emidence™ cloud platform is the place where rapidly emerging evidence based healthcare best practices, Occupational Health, and Occupational Medicine comes together thereby lowering system wide Total Cost of Occupational Health .  Our software platform also has integrated latest state fee schedules, state specific rules, clinical best practice guidelines, various state and federal health laws and EDI connectivity to provider networks. We are here to help you to manage your revenue cycle capably and make sure it yields positive returns.

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