• General
  • Why are we moving to ICD-10?

    ICD-10 is a more advanced and robust coding set than ICD-9. This allows for complex and detailed reporting that better meets the needs of the health care industry today. The move to ICD-10 will increase the level of specificity available for research, public health, and other purposes.

  • When is the compliance date for ICD-10?

    ICD-10 compliance is required for service on or after October 1, 2015.

  • Who is required to use ICD-10 codes?

    ICD-10 compliance is mandatory for all HIPAA covered entities, not only Medicare. There are no exceptions for any HIPAA covered entities. If entities are not covered by HIPAA they are not required to comply with ICD-10. This includes worker’s compensation and liability carriers.

  • Can I just “crosswalk” my ICD-9 codes to ICD-10?

    No. Crosswalks or equivalence mapping are for general knowledge and often map only to codes that do not contain sufficient specificity based on what is clinically known at the time of service. These unspecified codes may fail to provide medical necessity for the services rendered. “Native” or source document coding is recommended. In native coding, an ICD-10 diagnosis code is directly assigned based on information that is documented in the clinical record.

  • Can I just let my coder deal with ICD-10?

    ICD-10 requires more specificity and coders can only code based on the documentation available to them. If the documentation is not complete and does not provide the necessary detail, the coder will not be able to assign the most appropriate code. If you utilize the service of certified coders the documentation must have a level of specificity to assign the most appropriate codes for you.

  • I heard there might be another delay in ICD-10. Is that true?

    No. There will not be another delay in the ICD-10 transition deadline. CMS has advised that they will allow for a degree of flexibility during the first year of implementation. This flexibility includes several restrictions and does NOT apply to Medicaid, Commercial or other payors. For more details on CMS flexibility, click here.

  • Will our cash flow be impacted by the transition?

    Yes. To what extent may be within your control. To reduce the possibility of delayed or denied claims, you should document specific diagnoses with as much detail as clinically available at the time of service. This will ensure that the claim has the best possible chance to be adjudicated.

  • Will I need an ICD-10 code if I am requesting a prior authorization in September for an October service?

    This will depend on the payor. Be prepared to provide ICD-10 codes for ALL prior authorization related to service on or after 10/1/15.

  • Resource
  • I have an EHR, won’t it code for me?

    Electronic Health Records (EHRs) are valuable tools in the transition to ICD-10. Your system should have the codes available for you and may even help you select a code a particular situation. However, it is still important to understand the guidelines and structure of ICD-10 in order to select the most appropriate codes.

  • Where can I look-up ICD-10 codes?

    There are several resources for code look up and they all vary in their level of features and functionality.

  • Specific Complaint
  • Is the ICD-10 code for sciatica different that low back pain?

    Yes. The low back pain codes to M54.5, while sciatica codes to M54.3 with further specificity as to laterality (M54.31 right side and M54.32 left side). Additionally, there are separate codes for lumbago with sciatica which includes M541.41 for right side lumbago with sciatica and M54.42 for left side lumbago with sciatica.

  • What about obstetric (OB) cases?

    Documentation of trimester is required. To determine trimester, calculate from the first day of last menstrual period and is documented in weeks as follows:

    First trimester: Less than 14 weeks, 0 days
    Second trimester: 14 weeks, 0 days – 27 weeks, 6 days
    Third trimester: 28 weeks – delivery

    Other OB concepts in ICD-10:

    • The time frame for differentiating between early and late vomiting in pregnancy has been changed 22 to 20 weeks
    • The time frame for a missed abortion (vs fetal death) has changed from 22 to 20 weeks
    • In ICD-10-CM, an elective abortion is now described as an elective termination of pregnant
    • There are four spontaneous abortion definitions in ICD-10; use the appropriate definition in your documentation
      • Missed abortion no Bleeding, os closed
      • Threatened abortion Bleeding, os closed
      • Incomplete abortion Bleeding, os open, products of conception (POC) are extruding
      • Complete abortion Possible bleeding or spotting, os closed, all POC expelled
    • Documentation of conditions/complications of pregnancy need to distinguish between preexisting conditions or pregnancy related conditions
    • Include the following when documenting complications of pregnancy
      • Condition detail – was the condition preexisting, or present before pregnancy
      • Trimester – when did the pregnancy related condition develop?
      • Causal relationship – establish the relationship between pregnancy and the complication (e.g. preeclampsia)
  • What are the changes in ICD-10 for Acute Myocardial Infarction (AMI)?

    In ICD-10, AMI is considered acute for four weeks from the time of incident which is a change from ICD-9. Continue to report codes from category I21 for encounters while the MI is equal to or less than four weeks, including transfers to another acute setting or post acute care setting, and while the patient requires continued care for MI. For encounters after four weeks and while the patient is still receiving care related to the MI, the appropriate aftercare codes should be assigned. For an old or healed MI that does not require further care, code I25.2-ol MI may be assigned.

  • ICD-10 Concepts
  • What is episode of care (EOC)?

    In ICD-10 many diagnoses such as injuries and poisonings include episode of care into the code as the 7th character. Because the EOC character is the 7th character, the placeholder X is used to fill in the empty character fields for diagnoses that are otherwise 3-5 characters. The meaning of the different characters is as follows:

    • A – initial  encounter defined as “active treatment”
    • D – subsequent encounter which is for visits after the active phase of treatment but when the patient is receiving routine care for the injury during the period of healing or recovery
    • S – sequela encounter for “late effects” such as complications or conditions that arise as a result of an injury.

    For fractures, the 7th character options are expanded to include the Gustilo classifications for open fractures of long bones:

    • A – initial encounter for closed fracture
    • B – initial encounter for open fracture type I or II
    • C – initial encounter for open fractures type IIIA, IIIB or IIIC
    • D – subsequent encounter for closed fracture with routine healing
    • E – subsequent encounter for open fracture type I or II with routine healing
    • F – subsequent encounter for open fracture type IIIA, IIIB or IIIC with routine healing
    • G – subsequent encounter for closed fracture with delayed healing
    • H – subsequent encounter for open fracture type I or II with delayed healing
    • J – subsequent encounter for open fracture type IIIA, IIIB or IIIC with delayed healing
    • K – subsequent encounter for closed fracture with nonunion
    • M – subsequent encounter for open fracture type I or II with nonunion
    • N – subsequent encounter for open fracture type IIIA, IIIB or IIIC with nonunion
    • P – subsequent encounter for closed fracture with malunion
    • Q – subsequent encounter for closed fracture type I or II with malunion
    • R – subsequent encounter for closed fracture type IIIA, IIIB or IIIC with malunion
  • Can I still use unspecified codes in ICD-10?

    Yes. Unspecified codes are still acceptable if greater specificity is unknown at the time of the encounter. Your reported diagnoses should reflect the medical record and clinical knowledge of the patient’s condition. Unspecified codes should not be used as a shortcut, and should only be applied when more specific is not available at the time of service. For example, there is a code for sprain of unspecified deltoid ligament of the ankle but your documentation and code assignment should clearly indicate whether the patient has injured their right or left ankle.

  • Can I still assign Signs and Symptoms under ICD-10?

    Yes. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs(s)/symptoms(s) in lieu of a definitive diagnosis.

  • What does Severity of Illness really mean?

    Severity of Illness (SOI) reflects the patient’s level of sickness and disease complications. ICD-10 codes allow for improved support for documentation of illness. Examples include:

    • Chronic kidney disease, Stage I-V or ESRD
    • Ulcer staging, Stage I-V
    • Burn degree including whether it is extensive, and what percentage of TBSA is involved
  • What elements should be included in documentation for infections?

    When documenting infections include:

    • Type (cellulitis, viral diarrhea)
    • Location (specific anatomic site)
    • Acuity (acute, chronic, recurrent)
    • Causative organism (e.g. MRSA)
    • Complications (e.g. hypoxia, tachycardia)
    • Clinical manifestations (e.g. pain, fever)
    • Tobacco/ETOH involvement
  • What elements should be included in documentation for injuries and poisonings?

    When documenting injuries and poisonings include:

    • Location (specific anatomic site)
    • Laterality (left, right)
    • Where the incident occurred (geographic locations)

More ICD-10 News and Updates

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