2018 Coding Update

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

2018 Coding Update
As a new year begins, it is a good time to take a look at some of the coding and billing updates that may impact your practice.  Following are a few highlights for your consideration.
Training and Management of INR
The Centers for Medicare and Medicaid Services (CMS) added a new code for the training and initiation of home INR monitoring (93792).  In addition, code 93793 has been added for the payment of ongoing warfarin management.  The prior management codes (99363-99364), which were not payable by most insurance carriers and were bundled into an E&M service for Medicare, have been deleted for 2018.  Unlike 93793, training for initiating INR monitoring is payable on the same day as a separately identifiable E&M service.  Neither 93792 nor 93793 can be reported during the time periods assigned to the chronic care management or transitional care management codes.  Codes G0248-G0250, codes that are used when providing INR monitoring services for patients with mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism, are still listed as payable on the 2018 Medicare Fee Schedule.

Cognitive Assessment and Care Plan Services
Prior to 2018 there were no specific codes to report cognitive assessments and care planning.  The addition of 99483 enables these services to be described, addresses the gaps in providing care, and promotes quality of care by listing required elements.  Code 99483 lists 10 elements required for the code to be payable.  The guidelines state that if all the requirements are not met, the provider should bill the services with an E&M code.   The service is provided when a comprehensive evaluation of a new or existing patient exhibits signs and symptoms of cognitive impairment.  The evaluation is required to establish or confirm a diagnosis, and to identify the etiology and severity of the condition.  It includes a thorough evaluation of medical and psychosocial factors that potentially contribute to increased morbidity.  The creation of a care plan is a service to the patient.  Medical decision making includes current and likely progression of the disease; assessing the need of referral for rehabilitative, social, legal, financial or community based services; and, meal, transportation and other personal assistance services.  This is a code that can only be billed once every 180 days.
Pulmonary Diagnostic Testing
Codes 94617 and 94618 have been added to report dyspnea.  The previously used code 94620 has been deleted.  Code 94617 is used to report exercise testing.  Its descriptor reads, “Exercise test for bronchospasm, including pre- and post-spirometry electrocardiographic recording(s) and pulse oximetry.”  It includes a number of pulmonary tests and electrocardiographic recordings.  Code 94618, is used for pulmonary stress testing (e.g. six minute walk test) and includes the measurement of heart rate, oximetry and oxygen titration, when performed.  This code is used to report pulmonary stress testing including measurements of heart rate, oxygen levels (when performed), oximetry and oxygen titration.
Chest X-Rays
All nine previously used codes for chest x-rays have been deleted for 2018.  The new codes, 71045-71048, no longer reflect specific views of a chest x-ray, but rather differentiate simply by the number of views.  The new codes reflect common practice and allow for greater flexibility.  Medicare will continue to penalize those who are using old fashioned hard films when taking x-rays instead of newer computer radiology technology.  A modifier “FY” is required for claims using old technology.  These claims will be reduced by seven percent in 2018 on the technical component of the service.

Psychiatric Collaborative Care Management Services
Psychiatric Collaborative Care Management Services were released in 2017 as “G” codes.  These were deleted in 2018 and replaced by codes 99482-99494.  These codes for initial and subsequent care management mirror the “G” codes.   CPT chapter guideline are very helpful in use of these codes.

Diabetes Prevention  
CMS implemented a Medicare Diabetes Prevention Program (MDPP) expanded model for 2018.  The model has been tested and allows Medicare beneficiaries to access evidence-based diabetes prevention services.  The goal is to lower the rate of progression of Type 2 diabetes.  There are also several policy updates to MDPP.  Additional supplier enrollment requirements and compliance standards have also been adopted to enhance program integrity.

ICD-10 Codes
There are changes to Section I50 on Heart Failure for 2018.  Classifications are based on the American College of Cardiology and American Heart Association stages of heart failure.  They complement and should not be confused with the New York Heart Association Classification of Heart Failure.  There are inclusion terms that have been added related to ejection fraction, systolic heart failure, diastolic heart failure, and combined systolic and diastolic heart failure subcategories.  Codes now distinguish right ventricular failure from end stage heart disease, and chronic and acute (or decompensated) heart disease in the adult.  Cases of right heart failure and left heart failure are now differentiated.
The other significant coding update is under the Section I21 classification of Types of Myocardial Infarction (MI).   The following types of MI’s are now categorized:  

  • MI Type 1 - Spontaneous myocardial infarction
  • MI Type 2 - Myocardial infarction secondary to ischemic imbalance
  • MI Type 3 - Patients who present with death from a presumed cardiac etiology but without confirmatory cardiac biomarkers being available
  • MI Type 4 - Myocardial infarction associated with revascularization procedures
  • MI Type 5 - MI - Associated with coronary artery bypass graft surgery (CABG)

Flu Vaccine Reminder
As a reminder, the Fluzone High-Dose (Influenza Virus Vaccine) is covered under Medicare Part B (code 90662).  The code ONLY applies to patients ages 65 and older.  Be sure a patient meets this requirement or your claim for the vaccine will be rejected.

The Importance of Past Family History

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

The Importance of Past Family History
This month, we will look at past, family and social history as we work our way through the documentation elements of an evaluation and management (E&M) visit.  As I said last month, one must remember that the extent of history of present illness (HPI), review of systems (ROS) and past, family and social history (PFSH) that is obtained and documented is dependent upon clinical judgement and the nature of the presenting problem(s).

The history is unique from the Exam and Medical Decision Making (MDM) component of an E&M visit. For a complete history, a new patient requires information from all three of the history areas (HPI, ROS and PFSH).  The same circumstance for an established patient requires information only from two areas. 

As you can see from the chart from the 1995 Guidelines, two of the types of history for an E&M service (problem focused and expanded problem focused) do not need any PFSH.  That is the technical side of PFSH, but what about the practical side?

Looking at the behaviors encompassed in social history, I see additional challenges.  When asking a patient about smoking history, it is not just about current smoking habits, but whether they ever smoked.  It is not just about asking if they have smoked cigarettes, but whether they smoked other products as well.  In some instances, this may now include other legal items such as marijuana.  In the world of electronic medical records (EMR), there is a checkbox for “smoking,” but does it cover all the questions that this section encompasses?  Where does vaping get a check mark in the electronic record?  I am frequently critical of EMR systems and their limitations for this reason.  In this one section, several pieces of valuable information are reduced to a single check mark.  Does the next person looking at the lone checkmark by “smoking negative” assume all the above questions were asked and the answers were no to all of them?  Or, was it no to the ones that were asked?  Was the simple question of “do you smoke” the only one asked and is that what the checkbox showing a negative answer represents? Good questions to which there are no clear answers.

Both the 1995 and 1997 E&M Guidelines state that family history is: “A review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.”  Statements of “non-contributory” and “unremarkable” do not indicate what questions were asked of the patient, or if there were there any positive responses that the author was discounting.  It is for this reason that these two statements are not acceptable documentation according to the Centers for Medicare and Medicaid Services (CMS).  Again, write what the patient is asked and then document specific, valid information about the family history.   If either the chief complaint or ROS elicits a positive finding, it should be one of the topics of discussion about family members included in the PFSH.
I do appreciate the frustration physicians feel about obtaining a family history on a 90-year-old patient.  Frequently, the information gleaned from the conversation is not as specific as one might want because of the memory of the patient, or the lack of detailed medical information that was available 50 or 60 years ago. That does not mean the questions should not be asked and answers documented in the family history section.  Depending on the completeness of the rest of the visit, not having a family history documented could cause the note to be down coded from a new patient to an established patient. This would result in a significant loss of reimbursement. 

Review of Systems

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Review of Systems
A key component of an E&M visit is the review of systems.  This component of the history section of an E&M code documents the extent of the history of present illness, review of systems, and past family, and/or social history (PFSH) that is obtained and documented.  It is based upon clinical judgement and the nature of the presenting problem(s).

Both the 1995 & 1997 Evaluation & Management (E&M) Guidelines define the Review of Systems (ROS) as, “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.”  This system-by-system inquiry is focused on the subjective symptoms of the patient rather than the objective signs perceived by a clinician.  I frequently hear comments from physicians indicating they do not want to write things twice.  This comment is reflective of their confusion about the Assessment and Plan (A&P).  It is important to note that the analysis of the patient from a clinical standpoint is not the same as the ROS, which is a documentation of the patient’s comments.

The series of questions the clinician or ancillary staff asks the patient concerning each organ system and region of the body is done to gain an optimal understanding of the patient’s presenting illness and medical history.  Staff can document the ROS, but the physician must document confirmation of the information or add supplemental information.  The Guidelines state:
DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

The extent of ROS (as with HPI and PFSH) is dependent on the clinical judgement and nature of the presenting problem. When I am auditing charts and find a seemingly minor presenting problem, but see an extensive or complete ROS, my comments are that the chart is either under-documented (in reflecting the severity of the patient’s presenting problem), or over-documented with regard to the ROS.  Why would you need to document a ROS of 14 areas for a patient with a hangnail?  If, however, the patient has a history of diabetes and has already lost a couple of fingers and a foot, then perhaps that comprehensive ROS is appropriate to be sure nothing worse is going on with the patient.   Without proper documentation of the uncontrolled diabetes and previous problems, the presenting problem would seem minor and not warrant a comprehensive ROS.

One of the problems with Electronic Medical Records (EMR) is that it is very easy to click and quickly have a comprehensive ROS.  But was it “necessary?”  Was it appropriate based on the nature of the presenting problem as stated in the E&M Guidelines?  Over documentation of a ROS can lead to a code selection that is higher than that which is “medically necessary.”   When a chart is audited, medical necessity is determined by the insurer.  Do not over document a ROS just because you can.  Make sure the information you capture details that which you are using in evaluating the patient.  Insurers have stated multiple times that information that does not appear relevant based on the documentation of the patient’s presenting problem or history will not be considered.
When a patient does require a comprehensive review of systems, such as when he or she is a new patient, the E&M Guidelines state:
DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
A notation of pertinent positives and pertinent negatives followed by a statement of all other systems being negative, would be counted as a comprehensive review of systems.

When you are unable to obtain a ROS or other history information from the patient, do not just write “unable to obtain” the information.  Document why you cannot obtain a ROS and what efforts you made in trying to obtain information (i.e. attempts to contact other family members; calls to the nursing home; review of prior records).  There is no easy way to give “credit” when no elements of the history are documented.  Medicare educators have stated that providers should document their efforts and the auditor/reviewer will determine how much “credit” to give for those efforts.  The E&M Guidelines state:
DG:  If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.

Although the guidelines state what needs to be documented if you cannot get a history, there is no accommodation for what should be done to get any “credit” for history.  If the ROS / history element is not at a comprehensive level, visits such as a hospital admission cannot be billed in the code set as initial encounters, regardless of the level that the rest of the documentation for the visit supports.

Many physicians and auditors have believed that documentation of “unable to obtain history” gets you credit for a comprehensive history (which included a complete ROS).  Unfortunately, that is a myth.  I call it the Miller Myth.  This is named for a dear friend who challenged me several years ago to find a reference that supported giving ANY credit for the statement “unable to obtain history.”  I could not find any and honor him here for winning the challenge.   


Documentation of a Proper E&M History

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Documentation of a Proper E&M History
Does the visit really need a chief complaint in the documentation?  I get asked this all the time.  The resounding answer is yes.  Both the 1995 and 1997 Evaluation and Management (E&M) guidelines state, “The medical record should clearly reflect the chief complaint.”  The term “chief complaint” was defined in the 1995 E&M Guidelines as, “a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.”  The definition was expanded by the 1997 E&M Guidelines with the addition that the chief complaint (CC) be, “usually stated in the patient’s own words.”  Documentation starts with the “why” of the office visit, or the initial visit in the hospital.  The CC and subsequent History of Present Illness (HPI) set the stage for subsequent exams and workups of a patient and his or her illness.
These two critical areas of documentation state the patient’s view.  It is from this point that the rest of the note evolves.  It is not hard to see the significance of documentation that reflects a rash on a patient’s hand versus a rash that has been on their hand for two weeks, now spreading up their arm with increasing redness and tenderness.  The Review of Systems (ROS) and Physician Exam (PE) may be significantly different in intensity based on the additional information contained in the record. 
Another example I frequently see of documentation listed under CC and HPI is “needs refills.”  The 1997 Guidelines state the CC is usually in the patient’s own words.  Note the word “usually.” In this instance, the patient is most likely in for follow-up related to their chronic illness.  As a result, their chief complaint would be that treatment and management of the existing illness.  The HPI which is “a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present,” would document any changes in the chronic illness since the patient’s last visit.  The story of the patient’s problem is being told.
With only two levels of HPI scored for documentation, the difference in the amount of “detail needed to accurately characterize the clinical problem(s)” varies.  A brief HPI is warranted with only one or two elements documented if the patient’s illness is stable.  However, if the patient is having problems or has multiple stable illnesses then answers to a number of questions may be needed.  What is wrong?  How long has it been a problem?  How bad is it and what makes it better or worse?  Answers to these and other questions will give you the four HPI elements needed in documenting an extended history of the present illness or problem.  
After documentation of the HPI, the ROS is next.  Asking questions about systems directly related to the problem identified by the HPI and more are needed.  Clear documentation of the patient’s problem, its history and severity will flow easily in to the documentation.  Each section of documentation is based on information gathered from the prior section.  

This completes the discovery aspect of your verbal interaction with the patient.  Your documentation should reflect what is wrong with the patient and other items that you deem necessary to your clinical assessment based on your conversation with the patient.  The “story” of this patient’s history section is complete.

One note of caution:  using pre-populated templates for your chart documentation can be problematic.  Documentation in a patient’s chart should reflect what is needed for that patient, for that day, and for their set of complaints.  Entering an entire completed section of information by cutting and pasting or by pulling information forward does not show the unique nature of that patient.  I cannot tell you how many charts I audit where the ROS is contradicted by other parts of the chart.  My assumption is a cloned ROS was entered into that record.  Who knows if the questions were actually asked, but it is an incorrect and inaccurate section of documentation with potentially a significant financial impact.  Documentation must be specific to each patient encounter.  

Show Your Work to Assure Proper Payment

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Show Your Work to Assure Proper Payment
I was with a new client recently who wanted training on documentation of Evaluation & Management services (E&M).  He had been audited by a major insurance carrier and several of the visits reviewed were down-coded after their analysis.  There was no real explanation given to him.  The carrier’s only feedback was to reference the carrier manual reject code that indicated “documentation does not meet standards for code billed.”
Upon further review, it was clear that his documentation was deficient.  However, it was also clear that the patients were ill and presented complex cases warranting the higher reimbursement.  The cases were not over-coded, they were under-documented!
For an auditor, seeing documentation that a patient is ill, moderately ill or severely ill shows the “work” of the physician in the medical decision-making (MDM) process.  I believe inclusion of a few words can make all the difference to an auditor in validating that the documentation supports the level of service billed.
Many times I see documentation of a condition and wonder if the condition is new or not.  An earache that has been present for only two days seems to represent a new problem.  If the documentation states that the patient’s shortness of breath has been increasing, I am not sure if the condition is a new or ongoing issue for a patient with COPD or heart failure.  In your final listing of a diagnosis for the patient, be sure to indicate if the condition is new or not.  Remember, often when looking at your own charts many things are obvious to you that are not obvious to an auditor who does not have the clinical expertise you do.  Clear documentation can be very helpful.    
Another tip for reflecting the true status of a patient’s condition is to state whether the condition is an exacerbation or a flare-up.  If a diagnosis is listed without qualification, the default is for the condition to be considered stable.  A diagnosis of asthma for a patient coming in for a checkup is appropriate.  However, your documentation for a patient coming in sick with an exacerbation of their asthma should include “exacerbation” of asthma in the chart with additional notations for the asthma codes ( i.e. mild intermittent, severe persistent).  Complete documentation will give you the most specific diagnosis code.
If we look at the MDM, the Table of Risk has a listing of “mild exacerbation” and “severe exacerbation” for the moderate and high level, respectively.  If the remainder of the documentation and the medical necessity supports it, inclusion of “severe” would potentially lead to the highest level office visit (new or established patient), or highest level hospital visit (initial or subsequent care days).  Without “severe,” documentation of “asthma” alone does not show the severity of the patient’s condition and that same visit could be down-coded several levels by an auditor.  Without complete documentation, the severely ill patient looks like a healthy patient coming in for a routine follow-up visit.

Be sure to show the extent of your patient’s illness by including the appropriate descriptors in your documentation.  It may not change the diagnosis code, but it might affect the level of the E&M code.

New Year’s Wish for 2017 - Time for a Coder?

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

New Year’s Wish for 2017 - Time for a Coder?
As I look ahead to 2017 and consider the overall theme for my work in 2016 as a consultant, the International Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) is at the top of my list.  The transition to ICD-10 was hyped as an enormous change in coding.  In fact, ICD-10 is remarkably similar to its predecessor, ICD-9.  It is simply ICD-9 on steroids with many more codes to choose from.  It was not that ICD-10 is a new coding system, but rather an enhancement of the existing system.  The transition uncovered a substantial lack of understanding of the ICD-9 system.  The ICD-9 system is the foundation for understanding ICD-10.   Without a thorough understanding and solid base for the coding process, many found themselves failing to understand ICD-10 and ultimately overwhelmed by the transition process.

The guidelines for ICD-10 state that coding is a, “joint effort between the physician and the coder.”  The joint effort is critically compromised if the physician selects a code with no help or input from their coder.  To this end, my New Year’s wish is for physicians to be able to stop coding, which takes a considerable amount of time and effort.  Too often physicians spend an inordinate amount of time searching for codes, getting frustrated and then ultimately settling for an unspecified code.  I have too often seen that the most specific and appropriate diagnostic code is not used.
ICD-10 codes have compliance concerns of which physicians are not generally aware.  When an office files claims based on codes selected solely by physicians, the audits performed by my peers and I often find errors that could prove problematic for the physician.  Audits are performed looking at the selection and inclusion of these diagnostic codes.  This central piece of charting is generally done by physician-coders who have had little or no training in coding.  This is a recipe for problems.
Turn back the job of coding to the coders.  Calculate the amount of time you are spending trying to find diagnosis codes with software and on-line searches.  Multiply this by your average income per-hour and do the math.  You will find that there may be a strong economic argument to hire a full-time coder.  Your coding will greatly improve.  You can be more confident knowing you are up-to-date on new codes and other changes that ultimately impact your bottom line.  Most important, you the physician will find more time in your day to focus on the things you want to focus on -- the patient.

Timely Completion and Signing of Medical Records

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Timely Completion and Signing of Medical Records
One concern I often hear from billing staff has to do with the timely completion of medical records.  This issue has both billing and compliance ramifications.  A recent Medicare seminar I attended provided some interesting information on this topic that I thought I would share with you this month.  
For billing purposes, Medicare generally requires the following:  
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:

  • Reason for the encounter and relevant patient history, physical examination findings and prior diagnostic test results;
  • Assessment, clinical impression or diagnosis;
  • A plan for care; and
  • A date and legible identity of the observer.

While the issue of legibility has been largely addressed by increased utilization of electronic health records (EHRs), completion of the record through the inclusion of proper documentation and a dated signature continues to be of concern.  What does it mean for a medical record to be complete?  Is the record complete when it contains the documentation of the patient encounter but is not signed and dated?  As you know, you should not bill for an office visit or other service until documentation is on file supporting the level of service or code indicated for billing.  The file is not complete until the proper documentation is accompanied by a dated signature.  The question becomes, “How long do you have to sign and date the record in order for it to be accepted by CMS?”  The question is most important because EHR systems do not allow for back-dating of a signature.  As such, an auditor knows exactly when the signature of the provider was placed in the record.  How long is too long after the care is provided?

If you go to the website of your Medicare Administrative Contractor (MAC) you might find the answer.  The CMS/Medicare policy manual is specifically vague to allow the regional MAC’s medical directors the opportunity to set policy for their regions.  As a result, the answer as to timing varies from region-to- region.  CMS’s vague guidance is found in Chapter 12 of the Manual in the following statement, “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.” 
So what is your “requirement” for a timely signature?    Check with your MAC.  Some give reasonable direction, like WPS which states, “A reasonable expectation would be no more than a couple of days away from the service itself.”  Noridian states that they expect, “In most cases the notes would be signed at the time services are rendered.”  Palmetto is a little more direct stating, “Providers should not add a late signature to the medical record, (beyond the short delay that occurs during the transcription process).”  It is understood that there are circumstances, like waiting for transcription to be complete that might preclude signing the record at the time of service.  In general, it is best to sign the record at the time of service, if not within a day or two at the latest.

Signatures beyond a couple of days increase the likelihood that a claim will be denied because necessary documentation will not be accepted as being present due to a signature and date too removed from the time the care was provided.  This could be disastrous and costly in an audit.  For example, if every note that had a signature older than three days after the service was provided was not accepted by the MAC, then the provider’s documentation of work that was done at the time of the visit with the patient would not be allowed.  As a result, there would be no accepted documentation for the visit and payment would not be allowed even if an attestation statement was added at a later date.

To safeguard against these potential pitfalls, your practice should have policies that filing for services occur only after documentation is complete – including a dated signature.  This will give your billing staff guidance and keep their work compliant while holding yourself accountable for getting your documentation done in a timely fashion.  Most importantly, have a policy in place that that holds you and other providers in your office to a standard time period, perhaps 36 hours, to have a signature on the chart. These two policies will help ensure there are no compliance or billing issues caused by the lack of a timely signature.

No More ICD-10 Flexibility

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

No More ICD-10 Flexibility
The Centers for Medicare and Medicaid Services (CMS) recently released updated “Frequently Asked Questions” regarding the one-year timeline that allowed for “flexibility” in using ICD-10 codes.  It provides valuable insight into what CMS will do differently as of October 1, 2016.  The important information that I see is as follows:

  • There will be no further extension allowing for ICD-10 coding flexibility;
  • There will be no additional flexibility guidance;
  • There still will be instances where unspecified codes are acceptable;
  • Beginning October 1, 2016, all CMS review contractors are able to use coding specificity as the reason in an audit for denial of a reviewed claim; and
  • Providers should code claims to the degree of specificity supported by the encounter and the medical documentation

Claims previously submitted with unspecified ICD-10 diagnosis codes were not denied.  That will change; however, it is possible that an unspecified code will remain the most specific and appropriate code to use.  An example of this is a patient seen in the office with a diagnosis of bacterial pneumonia, unspecified (J15.9).  The provider has made a diagnosis. They empirically treat the patient and do not feel the need to obtain a culture to determine what type of bacterial pneumonia the patient has.   So, the unspecified code is the correct choice and the claim should be paid.  This should not change after October 1, 2016.
A different example would be a chart stating that the patient has hypertensive heart disease with heart failure (which would be coded as I11.0), but the diagnosis shown in the Assessment and Plan is listed only as “hypertension” and coded as I10.   In this example, the chart documentation has more specific information (hypertension with heart failure) than was coded in selecting I10 (essential hypertension). During an audit, the lack of alignment of documentation and diagnosis will be discovered and the claim would be denied and payment recovered by CMS.
This requirement of specificity in coding is for all encounters billed by physicians to CMS (or most payers) in any location.  Be sure when completing your note for a patient, your final diagnosis for the visit is as detailed as possible.  It may take an extra second of your time to be sure your diagnosis is at the highest level of specificity, but it will save you time and potential negative financial consequences when your documentation is audited.  Additional information is available at

Prepare for the End of “Close Enough” Coding

Prepare for the End of “Close Enough” Coding
I have been asked several times in the past couple of weeks what will happen on October 1 with ICD-10 coding.  Prior to the implementation of ICD-10 coding in 2015, the Centers for Medicare and Medicaid Services (CMS) issued a two-page document indicating that for the first 12 months of ICD-10 implementation, claims billed under the Part B physician fee schedule through either the automated medical review or complex medical review processes would be evaluated based on whether the physician/practitioner used a valid code from the correct family of codes. This process was to be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors and the Supplemental Medical Review Contractors.  As a result, there has been some leeway in the selection of diagnosis codes.
CMS stated, “for all quality reporting completed for the Program Year 2015 Medicare clinical data review contractors will not subject physicians to… penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the eligible professional (EP) used a code from the correct family of codes.  Furthermore, an EP will not be subject to a penalty if CMS experiences difficulty calculating the quality scores for Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM) or Meaningful Use due to the transition to ICD-10 codes.”  The only exception noted was if there was a specific CMS policy listing a specific payable diagnosis.
As discussed in prior columns, “close enough” meant “good enough.”  As long as you identified that the patient had a muscle strain, which arm did not need to be part of the code selected.  If your code showed that a patient had abdominal pain, it did not matter where the pain was located.  If you coded that a patient had asthma, coding for unspecified asthma was sufficient.  This general coding will be changing and preparation is essential. 
Many of the electronic health record (EHR) software uses General Equivalence Mapping (GEMS) or other cross-walking programs to aid you in the transition to ICD-10.   CMS indicated that the GEMS are a tool for converting ICD-9 data to ICD-10.  Confidence in the use of GEMS is evidenced by CMS stating that GEMS are, “a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9 data, including data for tracking quality, calculating reimbursement and converting to ICD-10 codes for use with payment systems.”   However, caution must be used when cross-walking.   Software is limited if the provider knows more about a patient’s illness and does not use the information.  The data is lost if the ICD-9 code previously selected was non-specific when using cross-walking software.  Perfect software would include the choices in the “family” of codes to show the provider what he or she might not have realized could be reflected in the code selection.  For example, in ICD-9 codes for asthma, there is intrinsic, extrinsic, chronic obstructive and unspecified asthma.  Converting intrinsic or extrinsic asthma from ICD-9 to ICD-10, may result in a code for Mild Intermittent Asthma.  But there are five different “severity levels” of asthma in ICD-10-CM.  In checking with pulmonologists, they indicate that patients with intrinsic or extrinsic asthma, may have a more severe form of asthma, such as severe persistent and not the mild intermittent.  Using the cross-walking software, you are lulled into a false sense of security that you have an “equivalent” code.  Some software I have used will crosswalk intrinsic asthma to the unspecified asthma code in ICD-10, which creates additional problems.  The other two diagnoses I used above as examples also code to either unspecified codes, or ones with a specificity that may not be what you intended.

So what to do?  First, have a list of your most frequently utilized ICD-10 diagnosis codes created for your review.  Look at it and compare it with your ICD-9 list from before the transition.  You should be able to spot the inconsistencies mentioned above.  Next, have your staff generate a list of your top 100 utilized codes.  From this list, look at those that say unspecified and take just a moment to ask yourself if you knew more than was reflected by the code used.    If so, look at an ICD-10 book so you can see the choices.  While this analysis may take a bit of time, we have no guidance from CMS as to what they will be doing differently.  Will they allow only “unspecified” codes for three consecutive encounters with a patient?  Will they deny unspecified codes all together?  We simply do not know at this point in time, yet we must still try to prepare. 
The language of the one-year moratorium states that it applies to “either automated medical review or complex medical review” processes.  That seems to indicate that your claims will be paid no matter what the diagnosis specificity, but it matters later when reviews/audits are done and the need for specificity is enforced.  As such, you may not know that there is a problem until a review is done.  So be proactive and be specific!

Coding with Specificity Has Its Benefits

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Coding with Specificity Has Its Benefits
ICD-10 Coding has garnered a great deal of attention in both this column and throughout the lectures that I have given over the last two years.  One area of focus that continually emerges is the importance of specificity in selecting a code.  I would estimate that I have presented on this topic to over 1,000 physicians representing most specialties.   The majority of physicians want to know why it matters.  Physicians argue that it does not affect the treatment of the patient.   Why should they waste time trying to find just the right code when the time could be better spent caring for patients?  Good question.   
Continuity of care is one reason.  In this electronic age sometimes the only information available to another physician providing care is a code number and its accompanying words.  The diagnostic code you assign helps other physicians understand the patient’s condition and the severity of the illness.  Many times, care is based on the history of care that other physicians have access to.   
Medical necessity is another reason.   Documentation and use of properly specific codes lends support to the level of service you are selecting for an Evaluation & Management (E&M) code.  In addition, it provides support for any procedure that is provided.  A properly specific code tells the WHY for a patient’s course of treatment.  
All too often physicians are choosing “unspecified” in a diagnosis family.  While payments are still being made, the Centers for Medicare and Medicaid Services (CMS) has indicated that effective October 1, 2016 “close-enough” coding will no longer be accepted in most instances.  This will become a problem for physicians using unspecified codes after this date where other more specific codes are necessitated.  It is important that you start planning now for this transition.    
It is not that for every patient seen there is always a diagnosis code with the specificity that the family of codes offers.  It is important to note, however, unspecified coding might be an appropriate code.  A patient with unspecified pneumonia as a diagnosis is a great example of the challenges presented.  You may know very little about the pneumonia and as a result treat the patient empirically and correctly code an unspecified pneumonia.  There are more coding options that you can use.  Is it a bronchopneumonia, lobar pneumonia, hypostatic pneumonia or some other type of pneumonia?  These are the other choices in the “Unspecified organism for pneumonia” family of codes as seen below:  
 In other diagnostic areas where an unspecified code would be less likely to be a representation of what the physician truly knows, I see it being selected.  An example is “unspecified abdominal pain” (R10.9) where the chart clearly indicates a location and whether it is a localized pain or one that is with rebound or just an abdominal tenderness.  Another common “unspecified” code selected is for patients with asthma.  Because of crosswalks, GEMS and often a lack of time, the quick easy code of Unspecified, asthma: J45.909 is selected.  There are 18 codes in the asthma family; four sections based on severity of the asthma within each section and three codes which reflect the status of that type of asthma.  
If you have a short list of common codes tacked up on the wall or printed on a sheet, you might not be coding with enough specificity.  Now that the hurdles and hysteria of implementing ICD-10 have passed, it is time to continue the learning process to do it right when it comes to diagnosis documentation and code selection.  As an added benefit, this will also have a positive effect on your
As I previously suggested during the conversion process, look at your top 25 utilized diagnosis codes.  Ask your biller/coder to run the list again looking specifically at the past three months so you are looking at your ICD-10 codes after you had a while to use them.   Look to see how many codes have the word “unspecified” in the descriptor or end in a digit of “9.”  Have your biller/coder look up in a book or online ( the words of the code and print out for you the choices associated with that illness or disease process.  While there may be a large number of choices, I have found that for most physicians seeing the options will allow them to understand what code choices exist.  Many times the list can be significantly reduced just by examining it and comparing the diagnoses to the types of patient’s they see.   Do just two codes per week.  If you have the proper data it should not take you more than 5-10 minutes to look over.  With the next patient seen, you will probably remember to stage the asthma (mild intermittent; mild persistent; moderate persistent; severe persistent) and indicate its status at this appointment (with exacerbation, with status asthmaticus or uncomplicated).  The time spent now will avoid hours of consternation and stress when “close-enough” will longer be accepted by CMS. 

Stay True to Why You Pursued Medicine.