ICD-10-CM: 5 Things Physicians Should Know to Prepare

Patient care is a physician’s first priority. However, cashflow keeps your practice’s doors open. This is all the more reason to dive into ICD-10-CM/PCS and begin to learn how it may affect your practice, says Sandra Draper, RHIT, CCS, director of education and development at Precyse, which provides specialty-specific ICD-10-CM/PCS education and documentation audits for practices nationwide.

Draper discusses important differences between ICD-9-CM and ICD-10-CM that physicians should keep in mind to prevent major disruptions in revenue.

[Note: To access the most up-to-date version of ICD-10-CM, visit the Centers for Disease Control and Prevention Web site to download the 2014 ICD-10-CM code set.]

  1. Laterality: Unlike ICD-9-CM, ICD-10-CM specifies left, right, and bilateral. For example, a patient presents with a cyst on his or her eyelid. To properly report the ICD-10-CM code for this condition, physicians must document whether the cyst is on the right or left lid. They must also specify upper vs. lower lid.
    What you need to know: Although ICD-10-CM provides an option for ‘unspecified eye,’ payers will likely not accept this code (H02.829) because it provides very little clinical information. Physicians should crosswalk any diagnoses on their superbill from ICD-9-CM to ICD-10-CM to determine whether any of the conditions require laterality. Laterality is a common theme throughout ICD-10-CM, so it’s likely that at least one condition on a superbill will be affected.
  2. Anatomical site or location: ICD-10-CM requires far more detail in terms of the location of an injury or condition. For example, a patient presents with a cerebral infarction due to an embolism. Physicians must document precisely where the embolism occurred, including laterality as well as the specific artery (i.e., in the precerebral artery, carotid artery, basilar artery, vertebral artery, middle cerebral artery, anterior cerebral artery, posterior cerebral artery, or cerebellar artery).
    What you need to know: Physicians should take the time to read through the ICD-10-CM code descriptions pertinent to their specialty to understand what type of clinical detail is required.
  3. Combination codes: ICD-10-CM includes hundreds of combination codes (i.e., codes that link symptoms, manifestations, or complications with a particular diagnosis). For example, ICD-10-CM code I25.10 denotes atherosclerotic heart disease of native coronary artery without angina pectoris. Code I25.11- denotes atherosclerotic heart disease of native coronary artery with angina pectoris. The sixth digit specifies more information about the angina pectoris (e.g., whether it’s unstable or with documented spasm).
    What you need to know: To report combination codes correctly, documentation must clearly indicate the presence of the symptom, manifestation, or complication along with the pertinent condition to which it corresponds. Documentation must also link the two together (e.g., coronary artery disease with unstable angina).
  4. Type of encounter: Some ICD-10-CM codes specify whether the encounter is initial, subsequent, or sequela. For example, a patient presents with a laceration of his or her right hip tendon. Physicians must document the type of encounter so coders can assign the 7th (and final) character in the ICD-10-CM code. An initial encounter is one in which the patient receives initial active treatment. A subsequent encounter is one in which a patient receives routine care during the healing or recovery phase. A sequela encounter is one in which a patient receives treatment for complications or conditions that arise as a direct result of a condition. The 2013 ICD-10-CM Official Guidelines for Coding and Reporting provide examples of each.
    What you need to know: The type of encounter is required for valid submission of certain codes. Those working in the orthopedic specialty should pay close attention to the 7th character, as it may also include other important information, such as the type of healing (i.e., routine, delayed, nonunion, or malunion).
  5. ICD-10-CM coding guidelines: If physicians assign their own codes, they must—at a minimum—read through the 2013 ICD-10-CM Official Guidelines for Coding and Reporting. This document is a treasure trove of information that includes little known facts that about the new coding system physicians could easily overlook. For example, ICD-10-CM requires inclusion of a placeholder character ‘X’ for certain codes to allow for future expansion. Code category T36-T50 (poisoning by, adverse effects of, and underdosing of drugs, medications, and biological substances) is one example.
    What you need to know: ICD-10-CM codes can range in length from three to seven characters, including placeholders. Only complete codes will be considered valid. Review the guidelines for more information about coding conventions and diagnostic reporting for outpatient services.

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

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