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!