ICD-10: It’s all about the specifics

ICD-10: It’s all about the specifics

November 2015
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Published in the November 2015 issue of Today’s Hospitalist

READERS CONTINUE to send in interesting questions each month. Here are two recent submissions and it’s no surprise that the first concerns ICD-10.

ICD-10
Our hospitalists are still struggling with ICD-10, which launched last month. Any suggestions?
Great question! Think about placing an order at your friendly neighborhood Chipper Chicken Drive-Thru. If you just order a bucket of chicken, who knows what you will get? But if you order a 12-piece bucket that’s grilled and all-white meat, you will (hopefully) get just what you wanted. Why? Because you provided all the right details.

The overarching idea behind transitioning from ICD- 9 to ICD-10 is to collect and report better data. ICD-10 is designed to provide very specific clinical informa- tion with a long list of goals in mind: the ability to mea- sure health care services, refine reimbursement meth- odologies, decrease the need to submit supporting documentation with claims (the ICD-10 codes say it all), perform more accurate public health surveillance, and measure parameters such as morbidity and mortality as well as disease outcomes.

Where is this all leading? Your documentation needs to include as much detail about a diagnosis or procedure as possible.

Detail, detail, detail
For ICD-10 diagnosis codes, those details should include factors such as location, laterality (right, left, unilateral, bilateral), acute, chronic, initial encounter, subsequent encounter, with complication, without complication, with or without infection, and so on.

When you’re treating a patient with pneumonia, for instance, document information like right or left side or bilateral, cause (such as aspiration or organism), and pneumonia with or without an associated condition such as influenza. These details benefit both you and your hospital by supporting the medical necessity of performing diagnostic tests and of your level of evaluation and management (E/M) services.

This summer, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association released a joint communication indicating that there would be a period of “leniency” for 12 months following implementation of ICD-10. That means that, in terms of post-payment claims audit activity, CMS auditors will not penalize providers if an ICD-10 code submitted is not to the highest level of specificity. This gives providers and hospitals some more time to become familiar with the new codes.

According to the guidance, all claims must be submitted with a valid ICD-10 code. But as long as claims include a valid code from the correct “family” of codes, the CMS will hold a provider harmless for purposes of claims payment audit activity. What does that mean? Let’s look a little closer.

Code families
“Family of codes” is the same as an ICD-10 three-character category. (As you probably know, ICD-10 codes can have up to seven digits. The first three denote category, while digits four through seven provide other specifics including etiology, site and severity.)

Codes within a category are clinically related. For example, COPD is represented by the three-character category of J44. Within that family are J44.0, J44.1 and J44.9, each representing a sub-divided classification representing greater specificity. (J44.0 is COPD with acute lower respiratory infection, J44.1 is COPD with acute exacerbation and J44.9 is COPD, unspecified.)

In its memorandum this summer, the CMS used the example of C81 (Hodgkin’s lymphoma). C81 by itself is not a valid code. Examples of valid codes within category C81 contain 5 characters, such as:

    • C81.00: Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site
    • C81.03: Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes
    • C81.10: Nodular sclerosis classical Hodgkin lymphoma, unspecified site
    • C81.90: Hodgkin lymphoma, unspecified, unspecified siteDuring the 12 months after ICD-10 implementation, the CMS will accept any one of the valid codes for Hodgkin’s lymphoma (C81.00, C81.03, C81.10 or C81.90) and will not subject any such claims to post-payment audit activity or potential recoupment.

But hospitals and physicians should use the grace period wisely. After next Sept. 30, the goal for all claims will be diagnosis coding to the highest and most accurate level of specificity.And while ICD-10 has been effect only since Oct. 1, here’s one common problem we’re already seeing: Billing claims for admissions are incorrectly using the date of admission, not the date of discharge.

Assisting in surgery
Occasionally, a hospitalist is asked to assist in a surgery for a patient he or she has been caring for. Can we bill for this, and do the hospitalists involved have to do a separate operative report?

Payment policy indicators on CPT procedure codes listed in the Medicare Physician Fee Schedule database identify whether a specific surgical procedure is eligible for a surgical assistant. You should review this fee schedule before any surgery is performed to see if that procedure allows for paying an assistant.Payment policy indicators are as follows:

    • 0: “Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.”Surgical assistants for procedures assigned this indicator may or may not be paid. The primary surgeon must submit documentation that clearly indicates the specifics of why a surgical assistant was needed for a procedure that does not automatically allow for one.
    • 1: “Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at Surgery may not be paid.”This indicator is pretty clear: The procedure does not require a surgical assistant and, therefore, no payment will be made.
    • 2: “Payment restriction for assistants at surgery does not apply to this procedure.”These procedures do not have restrictions related to a surgical assistant.

However, even in this situation, hospitalists employed by a hospital may have contractual restrictions preventing them from billing for assisting at a surgery. Before you submit a claim, find out what the hospitalists’ employment agreement allows them to do and bill.To answer the second part of your question: Medicare does not require a surgical assistant to generate a separate operative note. But primary surgeons should include the name and title of their surgical assistant in their operative report as well as the specifics of why that assistant was needed, if appropriate.

And be sure to use the appropriate modifiers when submitting claims for surgical assistants. Report modifier 80 for a surgical assistant, modifier 81 for a “minimum assistant surgeon” and modifier 82 if the surgical assistant is provided when a qualified resident surgeon is not available.

Sue A. LewisSue A. Lewis, RN, CPC, PCS, is a coding manager for a nonprofit health plan in the Midwest. Send any billing and coding questions you have to her at slewis56@q.com and we may answer them in a future issue.

 

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