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2013 Medical Billing and Reimbursement Alert: Big Changes Ahead

Kareo December 10th, 2012

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There are going to be a lot of factors that may affect your medical billing and reimbursement in 2013. Expect it to be a year full of changes. The following are some of the biggest issues that we are going to see in the next twelve months.

Medicare: It’s been 10 years since we’ve seen the government announce a raise in Medicare rates in conjunction with the release of a Medicare Physician Fee Schedule (MPFS), but history has not numbed us to the shock of seeing a 26.5 percent across-the-board decrease in physician reimbursement.
However, in a press release, CMS revealed its dedication to try to reverse the very cuts that it just announced, declaring: “The Administration is committed to… ensuring that these payment cuts do not take effect.” Under extreme pressure to enhance access for seniors, CMS is apparently just as frustrated as physicians, but for now the agency’s hands are tied.
Unfortunately, Medicare access and physician reimbursement are two of the many issues that Congress and the President must address to avoid plummeting over the “fiscal cliff” of mandated federal spending cuts in January. Don’t expect to learn the fate of Medicare reimbursement in 2013 until sometime in mid-January – possibly later.
RVUs: In addition to the massive reimbursement cuts forced by the conversion factor reduction, several specialties face significant reimbursement declines for another reason: reductions in the relative value units (RVUs) associated with CPT® codes those specialists frequently use. On the flip side, primary care specialties will see increases of three percent or more in 2013, thanks to upward revisions in the RVUs of many services they typically perform.
However, primary care physicians will also benefit from a measure that temporarily provides parity between Medicaid and Medicare rates. Taking effect January 1, 2013, and continuing for the next 24 months, primary care physicians and other eligible health care professionals accepting Medicaid will be guaranteed to receive rates at or equal to Medicare. The parity will be limited to evaluation and management (E/M) services and vaccines. Click here for the November 6, 2012 announcement that details the rate parity.
Payer Incentives: The reimbursement landscape for 2013 is also influenced by ongoing incentive programs for physicians and other eligible providers to encourage technology adoption.
Medicare’s eRx program continues in 2013 with a requirement to generate and electronically transmit 10 prescriptions by mid-year to avoid a reimbursement penalty. If you missed the June 30, 2012, deadline to do so, you may still have the opportunity to avoid the penalty – a 1.5 percent reduction applied to all Medicare reimbursement throughout 2013.
Another popular incentive program sponsored by the federal government, the Physician Quality Reporting System (PQRS), should get a great deal more attention next year. That’s because avoiding the imposition of PQRS penalties in 2015 will be based on successful PQRS performance in 2013.
More information has been released about the value-based modifier (VBM), which will be implemented on a widespread basis in 2017 but is already being fervently discussed. Don’t think of this modifier as one that is attached to a CPT® code. The VBM is not a coding convention; it’s a concept that will modify payment based on the “value” that the government deems appropriate to measure.
Patient-centered Medical Homes: Medical homes are also a likely hot topic for many physicians and other health care professionals going into 2013. Several organizations, including the National Committee for Quality Assurance (NCQA) and the Joint Commission, recognize practices as medical homes. In addition to validating the high performance of medical practices, recognition as a medical home is poised to become an important revenue source for practices, especially with the majority of states having one or more private payers that recognize medical homes with enhanced reimbursements. The medical home concept will likely spread further once the NCQA releases the details of a recognition program for specialty practices, expected in February 2013, considered to be an integral component of the patient-centered medical home “neighborhood.”
ICD-10: As if preparing for big changes in Medicare reimbursement and understanding myriad other changes in the MPFS isn’t enough, 2013 will also be the year to get serious about preparing for new diagnosis codes. After several fits and starts, ICD-10 will be implemented on October 1, 2014. With just more than a year to prepare for the inevitable, it is critical to learn this new and much more complex system. You’d be wise to also determine how your vendors plan to support it – and your efforts to adopt it.
Meaningful Use: In addition to preparing for ICD-10, be sure to assess your readiness for Stage Two of Meaningful Use, which will commence on January 1, 2014. The program continues the core/menu focus introduced in Stage One, but now there will be 17 core criteria plus three more to select from a menu of six. Two of the criteria required for Stage Two have sparked controversy among the medical practice community. One criterion is that five percent of your patients must download, view or transmit their health information. Another criterion calls for five percent of your patients to send you a secure electronic message. In other words, you’ll be held accountable for hitting electronic communication targets that you must ask your patients to do.

Once again, the old adage ‘change is the only constant’ seems to be truer than ever. 2013 will bring new challenges, but high performing practices have the vision to try and turn new requirements and other hurdles into opportunities for enhanced patient access and better revenue.

To find out more about these issues and their impact on your reimbursement, join me for a free webinar, Getting Paid in 2013, on Thursday, December 13. I’ll discuss all of these topics and how to maintain your fiscal health into 2013. Register here.

About the author: Elizabeth Woodcock, MBA, FACMPE, CPC is a professional speaker, trainer and author specializing in medical practice management. She has focused on medical practice operations and revenue cycle management for more than 20 years.

Kareo November 19th, 2012

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Why physicians can—and should—learn ICD-10
By Lisa A. Eramo

With ICD-10 comes greater specificity and a seemingly endless list of codes. Some have taken the initiative to understand the changes while others have lagged behind. However, ICD-10 is coming regardless of whether you want it or not. You’ve seen that if you have ready Part 1 and Part 2 of our update on ICD-10.

Why ICD-10 is beneficial
ICD-10 does include more code options and greater specificity; however, the changes are certainly manageable. In fact, physicians are more than capable of adapting to and learning what will be required of them, said Ginger Boyle, MD, CCS, CCS-P, a practicing family physician and physician advisor at Spartanburg Regional Healthcare System. Boyle spoke during a CMS ICD-10 National Provider call held October 25 about the health care system’s plan to educate physicians.

Although providers won’t need to learn ICD-10-PCS, they will need to become more familiar with ICD-10-CM codes, many of which are more specified than their ICD-9-CM counterparts, Boyle said. ICD-9-CM includes approximately 14,500 codes while ICD-10-CM includes nearly 70,000.

Some ICD-10-CM codes may surprise physicians who are accustomed to reporting more general—or even vague—ICD-9-CM codes to denote the same conditions.

For example, let’s look at diabetes in the practice setting. According to Boyle, patients with diabetes can have as many as 10 or 12 other diagnoses on their active problem list. Whereas ICD-9-CM codes remain fairly non-specific, ICD-10-CM codes for diabetes are combination codes. This means these codes include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. Thus, physicians must document all relevant information to nsure correct code assignment. ICD-10-CM code E11.21, for example, denotes Type 2 diabetes mellitus with diabetic nephropathy.

The good news is that ICD-10-CM allows physicians to make it very clear to payers where and why treatment is rendered, Boyle said.

For example, whereas ICD-9-CM codes for pain in the knee (719.46) and pain in the limb (729.5) are fairly generic, ICD-10-CM codes denote laterality. ICD-10-CM code M25.561, for instance, denotes pain in the right knee. ICD-10-CM code M79.662 (pain in left lower leg) denotes both laterality as well as the specific part of the limb.

The 5010 electronic format—a prerequisite of ICD-10-CM/PCS—also helps physicians more accurately depict patient severity. “One of the most important things from a physician’s perspective is that we’re going to increase the number of codes
we’re submitting. There is more space to describe the patient. Physicians can now outline more level of detail,” Boyle said.

Ultimately, the greater specificity in ICD-10 will only help—not hinder—physicians. “If we’re going to take care of our truly sickest patients, then let’s get credit for it,” Boyle added.

What you can do now

There are many steps that you can take now to ease the transition to ICD-10. According to Boyle, these include:

Identify your top 20 diagnoses and determine how ICD-10 will affect the documentation and coding of those conditions.
Create specialty-specific cheat sheets that include the most commonly-reported codes.
Ensure that coders receive in-depth ICD-10 training so they can educate others within the office about important changes.
Establish a process by which you’ll monitor reimbursement, denials, and rejections post-ICD-10 implementation.

If you haven’t yet read the first two articles in this series, check them out: ICD-10 and Coverage Determinations and Updates on ICD-10.

Kareo November 12th, 2012

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ICD-10 and Coverage Determinations

By Lisa A. Eramo

One of the big questions in physicians’ minds is: How will ICD-10-CM potentially affect coverage?

During the CMS ICD-10 National Provider Call held October 25, Janet Anderson Brock, director of the division of operations and information management for the coverage and analysis group at CMS, reiterated that Medicare coverage should remain unchanged after the transition.

“In order to preserve the coverage that we have on Sept. 30, 2014 and have the exact same coverage on October 1, 2014, we’ve gone through a pretty integrative
process,” Brock said, referring to CMS’ process of converting many of its national coverage determinations (NCD) from ICD-9-CM to ICD-10-CM/PCS.

CMS publishes NCDs that are applied nationally. Thus, the agency, itself, is responsible for converting codes from ICD-9-CM to ICD-10-CM/PCS in selected NCD publications.

CMS is currently in the process of determining which of its approximately 330 NCDs it will translate. Brock said CMS will translate approximately 40% of its NCDs. Some NCDs—particularly those related to non-coverage—may be obsolete and not require translation. Others may relate to durable medical equipment (DME) that either aren’t suitable for translation or that DME contractors will manage directly.

Local coverage determinations (LCD) are a different story. Individual Medicare Administrative Contractors (MAC) issue LCDs that are limited in scope and that cover a specific jurisdiction, Brock explained. “Each individual MAC will be responsible for doing its own translations [converting codes from ICD-9-CM to ICD-10-CM/PCS], and that’s because there is local variation,” she said.

Currently, national policy trumps any local policies in place. This won’t change in ICD-10-CM/PCS, Brock said. “If there is a national policy in place, there cannot be a local policy that comes through and modifies it in any way. Where there is no national policy in place, a local policy can dictate the coverage for that item or service,” she added.

Keeping up with ICD-10-CM

The race toward the ICD-10-CM finish line is nearly impossible if physicians aren’t informed along the way. Consider including these resources in your stockpile

Medlearn Matters article SE1239: Provides a helpful overview of ICD-10-CM/PCS benefits, timelines, and implementation tips
CMS ICD-10 industry email updates: The latest information from CMS sent directly into your email inbox
ICD-10 Basics for Medical Practices: A CMS guide and checklist to assist physician practices
ICD-10 Provider Resources: A one-stop shop for FAQs, a timeline widget, large and small practice implementation guides, and related links

Watch for information on learning how to use ICD-10 in Part 3 of our latest series on ICD-10. If you missed Part 1 of this series, read about it here.

Kareo November 8th, 2012

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Updates on ICD-10, Part 1
By Lisa A. Eramo

If ICD-10 isn’t part of your vernacular today, it most certainly will be.

“Every provider who reports diagnosis codes now will need to learn to use ICD-10-CM diagnosis codes,” said Pat Brooks, RHIA, senior technical advisor of the hospital and ambulatory policy group at CMS, during a CMS ICD-10 National Provider Call held October 25.

Fortunately, you won’t necessarily need to learn ICD-10-PCS codes—that is, the codes that denote inpatient procedures. That’s because you’ll continue to use CPT® and HCPCS codes for physician and ambulatory services, including physician visits to inpatients, said Brooks.

ICD-10 timeline
Hopefully, most physicians know by now that CMS delayed implementation of ICD-10-CM/PCS from October 1, 2013 to October 1, 2014.

What does this mean?
“The implementation date is the date of service for ambulatory and physician reporting,” said Brooks. “In other words, physicians who treat patients beginning on or after October 1, 2014 will report ICD-10-CM diagnosis codes for those services.”

Note that the implementation date for hospitals is based on the discharge date. Inpatient discharges occurring on or after October 1, 2014 will include ICD-10-CM and PCS codes.

Chris Stahlecker, acting director of the administrative simplification group in the office of e-health standards and services at CMS, said moving directly to ICD-11 is not a possibility.

“The ICD-11 codes aren’t available yet. If we look at how long it took for the ICD-10 codes to be developed, we couldn’t even envision ICD-11 codes available for several years,” Stahlecker said. “Quite frankly, we simply could not continue to exist on the ICD-9 code set. We can’t advance our healthcare delivery system based on code values that are becoming obsolete.”

What about changes in the interim?
You may be somewhat relieved to hear that no major coding changes will occur after ICD-10-CM/PCS implementation until October 1, 2015.

That’s because the ICD-9-CM Coordination and Maintenance Committee made its last regular, annual update to both ICD-9-CM and ICD-10-CM/PCS on October 1, 2011. The Committee will issue limited ICD-9-CM and ICD-10-CM/PCS code updates on October 1, 2012 and October 1, 2013 to capture new technology and new diseases, Brooks explained. On October 1, 2014, the Committee will issue limited ICD-10-CM/PCS updates to capture new technology and new diseases. Regular updates will resume on October 1, 2015.

“In the past, we had many updates to codes each year. These large code updates were extremely disruptive,” said Brooks. “This created problems for schools that were developing educational material, providers teaching physicians, and those working on the superbills trying to come up with the most common codes. The good news is that we’re in a partial code freeze.”

Watch for information on ICD-10 and coverage determinations in Part 2 of our latest series on ICD-10.

Kathy McCoy, MBA September 24th, 2012

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Everyone is talking about ICD-10-CM and ICD-10-PCS implementation. Since the extension of the deadline from October 1, 2013 to October 1, 2014 was announced, many wonder what we can really expect. Here are five facts about implementation that are without dispute:

October 1, 2014: a Deadline Without an Extension
It would be a mistake to consider the October 1, 2014 deadline for implementation of ICD-10-CM/PCS as flexible. On that date, all Health Insurance Portability and Accountability Act (HIPAA) covered entities must implement the new code sets. Billing for inpatients with dates of service or dates of discharge of October 1, 2014 or after must use ICD-10. While HHS has extended the implementation date in the past, there are no known extensions built into its present implementation schedule.
Non-covered Entities Should Use ICD-10-CM/PCS, too.
Workers’ Compensation and auto insurance companies are not covered by HIPAA, but that does not mean that for them ICD-10 is not a good idea. ICD-9-CM/PCS will no longer be maintained after October 1, 2014, so it is in non-covered entities’ best interest to use the new system. There is significantly more detail in the ICD-10 coding system, which will be of great value to both covered and non-covered entities.
ICD-10 Will Make Coding Easier
Some believe that the increased number of codes available to the ICD-10-CM/PCS system will make it more difficult to use, but ask yourself this. If you were looking to buy a quality reference dictionary, would you buy the smallest book available, or would you go for the biggest? So it is with ICD-10-CM/PCS. Its increased specificity will enable coders to make better quality selections more quickly. Because codes are grouped logically, getting to the right code is no more difficult than it has been with ICD-9-CM/PCS. In fact, alphabetic indexes and electronic coding tools currently in use in ICD-9-CM/PCS will be available for ICD-10-CM/PCS also. And over time, we should see more sophisticated electronic coding tools become available to take advantage of the new ICD-10-CM/PCS specificity.
Printed ICD-10 Code Handbooks are Available Now
We are all too familiar with the declining use of print media, and many fear that printed ICD-10-CM/PCS manuals are already a thing of the past. The truth is that manuals for both ICD-10-CM and ICD-10-PCS are available from a variety of publishers now. Shop around; manuals range in size from 700 to over 1800 pages in length and some are well illustrated. Yes, we are definitely in the electronic age, but ICD-10-CM/PCS is a system of coding that is independent of electronic hardware or software platforms and will continue to be supported by print publishers in the future. You can also find a great electronic ICD-10 Look-Up Tool on the ICD-10 Watch site—see the bottom right corner.
ICD-10 is Up-to-date Now
Keep in mind that ICD-10-CM and ICD-10-PCS are both codes and systems of coding. Since their initial development, ICD-10-CM/PCS codes have been updated annually to keep pace with continuous advances in medicine and technology. Code sets, or coding systems, continue to be updated as well, but will likely be “frozen” at some point prior to implementation.

Keep Forging Ahead

Kareo encourages you to continue your implementation efforts with research, planning, education, testing, and more testing. Stay up-to-date on ICD-10-CM/PCS with the following resources:

ICD-10-CM and ICD-10-PCS Frequently Asked Questions

ICD-10 (and ICD-9) Coding Handbooks

Latest ICD-10 news from CMS

ICD-10 email updates from CMS

ICD-10 posts on this blog

Lisa Eramo September 13th, 2012

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Although ICD-9-CM includes unspecified codes, practices should avoid reporting them, when possible.

Why?

They don’t provide any definitive information to payers, some of which will look for any reason to deny the medical necessity of services that physicians render, says Betty Johnson, CPC, CPC-I, CPMA, CPC-H, CPC-D, director of ICD-10 development and training at the American Academy of Professional Coders in Salt Lake City.

Unspecified codes—when reported frequently—can definitely subject physicians to third-party audits, says Johnson. Physicians can easily get into trouble when they report level 4 or 5 E/M codes with unspecified ICD-9-CM diagnosis codes, for example. This is problematic because payers may assume that the patient’s vague and unspecified diagnosis doesn’t justify the medical necessity of the intense level of E/M provided. It’s also easy for payers to assume that if the diagnosis isn’t documented properly, then the E/M level might not be documented appropriately either, she adds.

Aside from the potential financial ramifications, unspecified diagnosis codes also prohibit effective disease management and other research efforts, says Johnson.

It will become even more important to avoid unspecified codes once ICD-10 takes effect in 2014. That’s because ICD-10 includes more granular codes, and payers will likely question physicians who aren’t taking advantage of this added specificity, says Johnson.

For example, although ICD-10-CM does provide an unspecified option for otitis media (H66.90, otitis media, unspecified, unspecified ear), this code is so non-specific that it will most certainly raise a payer’s red flag, says Johnson. Instead, physicians should document laterality (i.e., whether the ear infection is in the left or right ear), which is not currently required in ICD-9-CM. Simply stating ear infection won’t be sufficient.

Likewise, ICD-10-CM does provide an unspecified option for asthma (J45.90-, unspecified asthma); however, physicians should avoid this code. Instead, they should document whether the asthma is mild, moderate, or severe as well as whether it’s intermittent or persistent. This will enable coders to report a more specified option, says Johnson.

Looking ahead

It’s too soon to tell how unspecified codes may affect physician reimbursement in 2014 and beyond because ICD-10-CM is vastly different than all of the other code sets that precede it, says Johnson. Even today, physicians are very dependent on each payer’s policy. Some payers may shift payment patterns for unspecified codes much more drastically than others. Some may deny claims entirely while others may require more documentation.

The good news is that physicians don’t necessarily need to document paragraphs of additional information. One or two terms (e.g., acute or chronic) can make a big difference in terms of coders being able to report a more specified code, says Johnson.

Johnson says that ICD-10 may eventually help with the adjudication process and reduce the number of denials that physicians receive simply because codes are more specific, and they tell the patient’s story more effectively.

What you can do now

Talk with your larger payers. Ask your payers whether they’re looking more closely at unspecified codes. If not, does the payer plan to do so in the future once ICD-10 takes effect?

Re-evaluate your templates. Can your EMR vendor make your templates more specific? Is there a user group that you can join to connect with other physician practices and better understand what your vendor might be doing to prepare for ICD-10?

Ensure that coders have access to medical records when coding. Some physicians may document a more specific diagnosis in the record but not on the encounter form. If coders don’t have access to the records, they must default to an unspecified code in these instances, says Johnson.

Lisa A. Eramo is a freelance writer and editor specializing in medical coding, health information management, and other healthcare regulatory topics. Visit her website at http://lisaeramo.wordpress.com/. Lisa wrote recently for Getting Paid on How Will Your Practice Transition Its Superbill to ICD-10?, Take a Closer Look at Your Superbill to Ensure Accurate Billing and Prevent Denials with More Accurate Medical Coding. Lisa has also written on Understanding RVUs: Ensure Accurate Reimbursement for the E/M Services You Provide.

Lisa Eramo August 28th, 2012

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It’s difficult enough today—in ICD-9-CM—to ensure that your superbill encompasses as many of the diagnosis and procedure codes you report on a regular basis. How will you ensure that it continues to do so once the volume of codes increases exponentially when ICD-10 takes effect in 2014?

Practices really need to start thinking about how they’ll revamp their superbill in preparation for the new coding system, says Mandy Thompson, CPC, coding and compliance consultant at Kraft Healthcare Consulting in Nashville, TN. Physicians don’t have the option to ignore the changes, as all providers must be prepared to report the new codes as of October 1, 2014, according to a proposed rule published in the Federal Register in April.

ICD-10 won’t affect procedure or supply codes, but it will affect the diagnosis codes that physicians report. Thompson says that many of the physician practices she audits nationwide are already starting to develop a strategy for how they’ll revise the superbill to accommodate the new codes.

The American Health Information Management Association (AHIMA) converted a sample superbill to from ICD-9-CM ICD-10-CM to demonstrate what the new form might look like. However, it cautions providers that the sample doesn’t represent an endorsement by AHIMA of the use of superbills or of this particular superbill format.

Know what you’re dealing with

Practices must determine how the ICD-9-CM codes they currently report will map to ICD-10-CM codes. In some cases, there may be a one-to-one mapping. In others, one ICD-9-CM code may map to multiple more specific ICD-10-CM codes.

A coder or biller should ideally be mapping the codes one-by-one to determine how the changes will affect their particular practice. The General Equivalence Mappings (GEM) can be extremely helpful with this task. The American Academy of Professional Coders (AAPC) provides a three-step mapping process that coders can use in conjunction with the GEMs to cross-reference ICD-9-CM with ICD-10-CM. The three-step process requires the following:

Compare and map all relevant ICD-9-CM codes with their ICD-10-CM counterparts.
Complete a backward mapping by reviewing every ICD-10-CM code with its ICD-9-CM predecessor.
Perform a quality review to remove inherent mapping flaws, clarify unspecified ICD-9-CM codes, and clarify combination codes and additional choices, etc.

To access the GEMs, visit http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-CM-and-GEMs.html and then click on ‘2013 General Equivalence Mappings—Diagnosis Codes and Guide.’ The file ‘2013_I10gem’ includes a backward map. The file ‘2013_I9gem’ includes a forward map. Note that codes in each column don’t include any decimal points. For example, ICD-9-CM code 0020 (which is actually 002.0, typhoid fever) maps to the following seven different ICD-10-CM codes:

A01.00, typhoid fever, unspecified (listed as A0100)
A01.01, typhoid meningitis (listed as A0101)
A01.02, typhoid fever with heart involvement (listed as (A0102)
A01.03, typhoid pneumonia (listed as A0103)
A01.04, typhoid arthritis (listed as A0104)
A01.05, typhoid osteomyelitis (listed as A0105)
A01.09, typhoid fever with other complications (listed as A0109)

In addition, the AAPC offers on its Web site a code translator that allows coders to map codes from ICD-9-CM to ICD-10-CM and vice versa. However, the AAPC includes a disclaimer stating that this shouldn’t be the only tool on which coders rely. Practices can also purchase a specialty-specific crosswalk from the AAPC that includes the 50 most frequently-used codes.

Specialty practices may want to consider creating one superbill specifically for diagnosis codes and another for procedure or HCPCS codes to accommodate the changes, says Thompson. Including the diagnosis codes on a separate page means that practices can print more code options from which physicians can choose. She says one orthopedic practice with which she worked plans to do this simply because of the sheer volume of code changes related to diseases of the musculoskeletal system.

Lisa A. Eramo is a freelance writer and editor specializing in medical coding, health information management, and other healthcare regulatory topics. Visit her website at http://lisaeramo.wordpress.com/. Lisa wrote recently for Getting Paid on Take a Closer Look at Your Superbill to Ensure Accurate Billing and Prevent Denials with More Accurate Medical Coding. Lisa has also written on Understanding RVUs: Ensure Accurate Reimbursement for the E/M Services You Provide.

Additional Resources

Betsy Nicoletti, M.S., CPC May 23rd, 2012

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“She was bitten by a dog. How much clearer can I be?”

“He fell. That’s what I wrote on the encounter form. He fell.”

When it comes to injuries, it often seems that physicians and coders are speaking in different languages. Physicians are speaking in English and coders are speaking in—well—code. Why aren’t “dog bite” or “fall” sufficient diagnosis codes?

Diagnosis coding rules require that when medical practices submit a claim for an injury, the injury itself (laceration, contusion, fracture, sprain) be listed first and the cause of the injury (dog bite, fall) be listed second. These causes, called “external causes” in ICD-9, begin with the letter E. E codes may never be used in the first position on the claim form. Use the physical injury first and the cause second.

The E codes are located after the V codes in the ICD-9 book and are titled, “Supplementary Classification of External Causes of Injury and Poisoning (E000-E999).” According to the Official Guidelines, E codes are used to describe the activity of a person seeking care at the time of the accident, as well as other health conditions related to the injury. The introduction in the Guidelines state, “E codes capture how the injury, poisoning, or adverse effect happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the person’s status (e.g. civilian, military), the associated activity, and the place where the event occurred.”

In ICD-9, E codes may be used with any code in the range 001-V91. The coder is instructed to use as many E codes as is necessary to describe the cause, intent and place of occurrence. They may never be a principal diagnosis, so the result of writing simply “dog bite” or “fall” will be that the claim is denied. As more providers are selecting their own ICD-9 codes in their Electronic Health Records, it is important that they understand the correct use of E codes, and that the software have an edit that will stop the claim before submission if the E code is used alone, or is first.

What if an injury ICD-9 code is submitted without a cause? That is, “contusion” without “fall”? Most payers will deny or suspend the claim, and ask for more information. What if “fall” is submitted without “contusion”? The denial reason will be something like this: “Principal diagnosis: invalid; must not be an external cause of injury code.” Correctly submitting the diagnosis codes when the claim is submitted the first time can speed payments and prevent the need to handle the claim a second time. These codes are frequently used in emergency departments and urgent care centers, but are also used for visits to patients in nursing homes and in primary care offices, orthopedics and for chiropractic services.

ICD-10 will require this same format

Although the timeline for ICD-10 implementation is in question, when medical practices do adopt it, coding for injuries will require this same format in addition to seventh digit extenders for injury codes. This seventh digit will indicate whether it was the initial encounter for this injury, a subsequent encounter or a long term after-effect. In addition, the practice will need to report the external cause of the injury at every visit for that condition. The first time the clinician sees the patient for that injury, the practice will need to report three additional occurrence cause codes. These external cause codes will indicate the place of occurrence, the activity the patient was engaged in and identify the patient (military, civilian, etc).

For now, medical groups that treat injuries should review the use of E codes by reading the guidelines related to the codes and reminding clinicians that they are never listed in the first place on an encounter form.

Betsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org.

You can join Betsy Nicoletti in a complimentary webinar, Stop Denials in Their Tracks: Get Paid the First Time by Health Care Insurers, on June 19 – register now. She has also written for Getting Paid recently on:

Kathy McCoy, MBA May 16th, 2012

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What if every air traveler coming to the US had to transfer to an antique aircraft before entering American airspace because our systems were not compatible internationally? As we continue to use ICD-9 in an ICD-10 world, coding of contemporary health data presents a similar dilemma.

Delaying the Delayed

ICD-10 expands by thousands the number of medical diagnosis and in-patient procedure codes used for clinical, billing, and financial systems of healthcare providers, payers, and other covered entities, thereby allowing much greater specificity in coding and later research. The U.S. is the last major country in the world that has not yet fully implemented ICD-10. On April 9, 2011, Health and Human Services proposed a shift in its deadline for implementation of ICD-10 from October 1, 2013 to October 1, 2014. (Note: Comments on the proposed rule that would delay the compliance date for ICD-10 from 2013 to 2014 are due to HHS no later than 5 p.m. eastern time May 17.) This is the second time in three years that HHS has delayed its implementation of the new code sets. And as of Tuesday, the AMA is urging CMS to further extend the ICD-10 deadline at a minimum to Oct. 1, 2015.

While some may bemoan the high costs for conversion to ICD-10, most understand that the conversion must happen. ICD-9 has been in use since the mid-1970s and was not designed for the current medical/technological environment. Implementation of ICD-10 will bring greater coding accuracy, higher quality health information and even better care.

There’s One Path

But would it be better to wait for ICD-11, scheduled for delivery to the World Health Assembly for official endorsement in 2015? Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, says no. “ICD-10 is the pathway to ICD-11,” she said. “You have to treat it like you’re building a structure starting with a first floor. You can’t build a fourth one without constructing a second and third.”

Implementation of ICD-10 is a long time coming. In a related blog post, Rhonda Butler, senior clinical research analyst with 3M Health Information Systems, said, “Unless we willfully ignore our own human nature, we should expect the same slow-mo street fight to implement ICD-11, lasting roughly two decades.” Rhonda continued, “Let’s go ahead and implement ICD-10 in 2013 or 2014, and decide now to implement ICD-11 in 2024. Planning now for ICD-11 would have the added benefit of establishing a new expectation in the industry—that regular upgrades to any system that facilitates the exchange of data is normal and expected.”

Positive Signs

We may be further along than many think. In a recent poll sponsored by the ICD-10 Watch blog, only 5% of respondents said that they need the additional year to implement ICD-10. A heartening 82% of all respondents said that they could use the extension but feel that they would have made the 2013 deadline. Only 9% stated that they need two more years to finish conversion.

Plan Now

So what’s the bottom line? Don’t let the new deadline allow you to put off your ICD-10 implementation work. Kareo encourages you to think ahead and plan for the ICD-10 transition on October 1, 2014.

Resources:

Getting Paid blog posts on ICD-10

Recorded Kareo Webinar: How to Prepare for ICD-10/5010 to Reduce F41.1 (Anxiety Reaction)

Recorded Kareo Webinar: Preparing for ICD-10-CM: The Nitty-Gritty of Diagnosis Coding

ICD-10 CM and ICD10-PCS Frequently Asked Questions

Latest ICD-10 news from CMS

ICD-10 email updates from CMS

Kathy McCoy, MBA April 9th, 2012

1 Comment Latest by COMMENTOR NAME

A proposed rule from HHS pushes the compliance deadline for conversion to ICD-10 back by one year to Oct. 1, 2014. HHS Secretary Kathleen Sebelius announced in February her intention to initiate the rulemaking process to postpone the ICD-10 deadline for compliance.

Sebelius announced the new proposed deadline in an e-mailed news release from HHS. More details are available in a CMS fact sheet.

2013 Medical Billing and Reimbursement Alert: Big Changes Ahead

Kareo December 10th, 2012

CMS Urges Physicians to Move Forward with ICD-10, Part 3

Kareo November 19th, 2012

CMS Urges Physicians to Move Forward with ICD-10, Part 2

Kareo November 12th, 2012

ICD-10 and Coverage Determinations

By Lisa A. Eramo

CMS Urges Physicians to Move Forward with ICD-10

Kareo November 8th, 2012

Five Facts about ICD-10 Implementation

Kathy McCoy, MBA September 24th, 2012

Know How Unspecified ICD-9-CM Diagnosis Codes Could Hurt Your Practice’s Bottom Line

Lisa Eramo September 13th, 2012

How Will Your Practice Transition Its Superbill to ICD-10?

Lisa Eramo August 28th, 2012

Why Isn’t “Dog Bite” a Valid Diagnosis Code? Diagnosis Coding Rules Explained

Betsy Nicoletti, M.S., CPC May 23rd, 2012

ICD-10 Delay – What Do We Do Now?

Kathy McCoy, MBA May 16th, 2012

Breaking News: HHS Proposes Delaying ICD-10 Deadline to Oct. 1, 2014

Kathy McCoy, MBA April 9th, 2012

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ICD-10 and Coverage Determinations

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Kareo November 8th, 2012

Kathy McCoy, MBA September 24th, 2012

Lisa Eramo September 13th, 2012

Lisa Eramo August 28th, 2012

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